Did you know? Every time a doctor prescribes medication, your pharmacy benefit manager (PBM) is working behind the scenes to protect your health and lower your costs. PBMs deploy advanced tools to help doctors and patients make more informed decisions when prescribing drugs, including Real Time Benefit Tools (RTBT) and electronic prior authorization (ePA).
Recently, PBMs have worked closely with employers and health insurers to improve their electronic systems, streamline the prior authorization process, and address challenges faced by patients. Our industry understands that some challenges and frustrations remain; that’s why we continue to identify pain points and refine these tools to better support patients, providers, and pharmacists.
When prior authorization tools work appropriately, they promote lower-cost, and safer pharmacy experiences by:
- Lowering costs by supporting better prescribing decisions
- When integrated together, RTBT and ePA provide visibility into a patient’s insurance coverage and lower-cost therapeutic alternatives at the point of prescribing. This allows patients and providers to make informed decisions before the prescription reaches the pharmacy, helping avoid surprises and reduce out-of-pocket costs.
- Preventing potentially harmful outcomes
- Prior authorizations help ensure that the right drugs are prescribed for the right patients. Prescriptions are compared to FDA-approved indications, dosage guidelines, and a patient’s medical history to flag any potential drug-drug interactions or problems that could arise due to a patient’s health conditions.
- Accelerating patients’ access to medications
- Enables faster prior authorization determinations, helping patients start therapy sooner and reducing treatment delays.
- Reducing administrative burden for providers
- Replaces manual phone, fax, and paper-based processes with streamlined electronic workflows for providers, plans, and PBMs.
- Improving workflow efficiency
- Supports automated review of requests that meet established criteria for a patient’s insurance coverage, allowing resources to be focused on more complex cases.
- Enhancing coordination across the health care system
- Facilitates secure, standardized data exchange between providers, PBMs, pharmacies, and health plans.
Technology exists to ensure that patients know their most affordable drug options before reaching the pharmacy. That’s why PCMA champions improved interoperability standards to reduce the barriers that too often stand in the way.
Expanding the use of these tools isn’t just about streamlining processes. It’s about helping patients get the right medications faster, safer, and at a lower cost.