Jan 16 2023

New Year Brings New Opportunities to Help Patients Maximize Plan Benefits and Reduce Costs

Research conducted during 2021 open enrollment found that among patients considering a change, nearly 30% were doing so for cost-related reasons, with 18% citing excessive out-of-pocket costs.

These findings are in addition to the estimated one-third of patients who report being unable to obtain a prescribed medication due to a lack of plan coverage.

As 2023 begins, pharmacists have a tremendous opportunity to help all patients – those who switched to new plans, those who stayed with their existing coverage, and those without coverage – obtain medications at a cost they can afford.  

The solution is referred to as “Real-Time Prescription Benefit” (RTPB).  It allows critical capabilities at point-of-care that include:

  • Access to medication benefit information included in each patient’s plan.
  • Identification of therapeutic alternatives that are covered by a patient’s plan.
  • Price information for each medication, including patient out-of-pocket costs.
  • Ability to avoid medications that require prior authorization and suggest alternatives.

Surescripts, the company that revolutionized the medication prescription process with its electronic prescribing solution, is pioneering RTPB technology for pharmacies.  The company’s Real-Time Prescription Benefit for Pharmacy solution currently provides access to plan information for nearly 80% of insured Americans – roughly 254 million patients.  

All RTPB-related information appears within a patient’s account and is seamlessly managed and stored within PrimeRx™.

Consider a few measures of the Surescripts® solution’s success:

  • Alternatives for non-covered medications: The solution successfully offers therapeutic alternatives for 32.5% of instances in which a requested medication is not covered by a pharmacy benefit manager (PBM).
  • Prior Authorization alternatives: When a requested medication requires a prior authorization, the solution identifies an alternative that doesn’t require a prior authorization 19.85% of the time.
  • Copayment Management: When a requested medication requires a copay of more than $50, the solution recommends a less-costly alternative 32.89% of the time. A few specific examples include:
    • A prescription for Chlorzoxazone 250mg tablets required a copayment of $560.00.  Real-Time Prescription Benefit identified an alternative with a copay of $0.93.
    • A prescription for Briviact, 50mg tablets, required a copayment of $479.91.  The solution identified an alternative with a copay of $4.14.
    • A prescription for Spravato 84mg (28 mg x 3) nasal spray required a copayment of $150.  But an alternative was identified with a copayment of $1.34.

Clearly, the Real-Time Prescription Benefit solution can have measurable and immediate savings.  For many Americans, this can mean the difference between leaving the pharmacy with an affordable medication and going without.  And, with direct integration available to PrimeRx™ pharmacies, it’s never been easier to access this important capability.