Physicians and hospitals may be overlooking powerful tools available as part of the electronic prescribing (ePrescribing) process. Formulary and benefit (F&B) information for medications is a case in point.
F&B is core to ePrescribing transactions and foundational to other downstream transactions like real-time benefit check that provides patient-specific out of pocket costs for medications and electronic prior authorization that is integrated into the electronic health record (EHR). While F&B has been around for over 20 years, many prescribers may not access this information consistently or only access it for complex visits. This may be a missed opportunity for less expensive, more therapeutically appropriate medications, especially because much work has been done over the years to make the information in F&B more complete and accurate.
F&B files give providers basic pharmacy benefit plan information during the drug selection process, such as the formulary tier. F&B files can also flag prior authorization, step-therapy or quantity limits, along with listing other covered drug alternatives. Using F&B information consistently at the point of ePrescribing has many benefits. For example, it can improve:
- Patient satisfaction. There is compelling value of enhanced formulary data to increase care quality and provider and patient satisfaction. With access to a list of effective and less costly therapeutic alternatives, providers can demonstrate better management of care for their high-risk patients—reducing time-to-therapy with less administrative overhead. ePrescribing a therapeutically appropriate, cost-effective drug also helps improve patient satisfaction by avoiding surprises at the pharmacy.
- Medication adherence and outcomes. Research shows that price is the primary reason patients abandon prescriptions or alter medication schedules to save money. Medication non-adherence results in 100,000 deaths each year and costs the US healthcare system $200 billion in unnecessary hospitalizations and doctor visits. In addition, with value-based contracts, providers are required to track and manage medication adherence metrics for their patient populations. F&B checks at the point of prescribing can help prescribers avoid prescriptions not covered by a patient’s pharmacy benefit. When eligibility is checked and a matching eligibility response is found, first-fill adherence increased by an additional 2.7 percentage points, and more often than not, prescriptions were sent to mail-order pharmacies, an option that has been shown to improve medication adherence on its own.1
- Administrative efficiencies. Using F&B information at the point of care enables physicians to ePrescribe a covered drug from the beginning. The result: administrative efficiencies from fewer phone calls between the pharmacy and the physician’s office and less prescription rework for alternative prescriptions when the patient realizes at the pharmacy that the prescription is unaffordable. That translates into saved time and money for the physician and the clinic staff.
F&B files have continuously improved over time and have real value, but more innovation is coming. The new V5 Formulary and Benefit standard, from the National Council for Prescription Drug Programs (NCPDP), will enhance F&B data in the EHR. Updates include:
- Identification of the date of the F&B file. This should help engender trust in the data by alerting providers if the information they are viewing is out of-date.
- Diagnosis code, which provides support for indication-based formularies. The EHR will be able to indicate coverage of the drug for specific diagnosis; and whether prior authorization is required for certain diagnosis, among other details.
- Support for medical/pharmacy coverage. With this field, payers and Pharmacy Benefit Managers (PBMs) can indicate if a drug is covered under the patient’s pharmacy or medical benefit. This is important because nearly half of specialty medications are covered under the medical benefit.
- Specialty drug indicator. This indicates whether a specialty medication is being prescribed, which can kick off additional workflows to support the specialty medication prescribing process.
Physicians, hospitals and health systems should begin thinking now about how this additional information may impact ePrescribing workflows and how to craft best practices to use this additional information and gain the best outcomes. Although mandatory adoption under Medicare Part D is likely to be a few years away, health systems should begin speaking with their EHR partners about how they plan to deploy these new capabilities in future EHR releases.
Providers can act today to work toward improving patient satisfaction, outcomes and administrative efficiencies by incorporating F&B information into their ePrescribing process. With the decades of improvements to the F&B information, providers should experience highly accurate and usable F&B information in their EHR, and administrative leaders can provide education and communication about the value of F&B, especially to providers that have not used the information in the past few years.