Prescribing cost-effective specialty medications including those covered under a medical benefit requires physicians to have access to drug-specific information on plan coverage and restrictions. Currently, many physicians can only see that a medical benefit drug is not covered as part of the pharmacy benefit with no additional information.
The CMS’ proposed rule requires Part D sponsors to integrate a real-time benefit tool (RTBT) within an electronic medical record (EMRs).
This proposed rule overlooks the option of offering enhanced Formulary and Benefit (F&B) as a solution for prescriber access to more complete drug benefit information.
Formulary and Benefit (F&B) data is central to providing prescribers using Electronic Health Record systems (EHRs) information from payers on drug coverage and formulary preferences. The National Council for Prescription Drug Programs (NCPDP) determines the standard, called Formulary & Benefit Standard, for exchanging the information electronically.
A recent announcement from the Centers for Medicare & Medicaid (CMS) has opened the door for Medicare Part D plans to use indication-based formularies beginning in 2020. This policy expansion provides a new tool for Part D plans to leverage costs and communicate formulary status to better inform prescribers and patients while solidifying what commercial payers may have been doing all along by using Prior Authorization (PA).
Recently BenMedica hosted a roundtable of physicians to share their perspectives on EHR formulary data. We were particularly interested in obtaining feedback on formulary data as it appears in EHRs (discussed in this article) and the value of real-time pharmacy benefit information in the EHR.
The following are the key takeaways from the roundtable regarding the new real-time pharmacy benefit information that will be appearing in EHR systems.
A notable statistic emerged during a United Healthcare presentation at AMCP this past April regarding their PreCheck MyScript pilot:
22% Of Prescription Decisions Were Influenced By Real-Time Information
This occurred in the first 120 days of the service being active and included more than 1 million prescriptions. That’s at least 220,000 prescriptions that needed to be edited and the work fell to providers.