Beginning January 1, U.S. Centers for Medicare & Medicaid Services (CMS) mandated certain capabilities be available for Part D plans. Here’s what you need to know:
Real-Time Benefit Tool (RTBT)1
- What is RTBT?
Often, a member is not aware if their insurance covers their prescribed treatment, or if less expensive therapeutically equivalent options are available, until they pick up a prescription.The RTBT allows the patient and prescriber to check if a prescription is covered by a member’s plan at the point of care.
- What is Abarca’s RTBT?
Darwin’s RTBT offering involves two main transactions – a request and a response:- The prescriber initiates a patient medication benefit check (PBMC) request at point of care to review member-specific benefit and coverage information.
- Once the PMBC request has been validated, Darwin responds with formulary alternatives for the submitted drug, any applicable utilization management coverage alerts (for example, prior authorization, quantity limit, etc), generic alternatives, and pricing information.
- How does it benefit members?
Because the patient will know if a medication is covered and the cost before he or she leaves the physician’s office, it prevents sticker shock at the pharmacy and reduces the likelihood that the pharmacist will have to call the doctor for approval to fill the prescription or a denial because there are formulary alternatives available.Abarca’s RTBT promotes cost transparency for members, provides them opportunities to save money, and increases the likelihood of medication compliance.
Electronic Prior Authorization (ePA)2
- What is ePA?
Prior authorization is a process used by health plans to ensure that a prescribed treatment is necessary, appropriate, and safe for the patient. This transaction is often handled manually, whereby the plan requests additional documentation, and the provider responds by phone, mail, or fax. This is a time-consuming process that can cause delays in care.Electronic prior authorization (ePA) is an electronic process that provides integration between Electronic Medical or Health Records (EMR/EHR) and Pharmacy Benefit Management Software enabling real-time approval of medication prior authorization at point of care.
- How does Abarca approach ePA?
Abarca’s ePA solution is fully integrated with the Coverage Determinations Module within the Darwin Platform. The key to Abarca’s approach to ePA is the same as its approach to business generally: We work to increase transparency.Through Darwin, when prescribers submit their requests, they receive immediate insight into the information required for a determination, as well as any documentation that may be missing. Once submitted, the request can be monitored through the review queue–speeding up the process significantly and reducing the need for manual follow-up.
- How does it benefit members?
By cutting down the time it takes for members to receive their medications and providing checks to ensure this is an appropriate treatment, Abarca’s approach to ePA helps improve adherence and reduce prescription abandonment.
Above all, both of these functionalities will contribute to a better experience for members. And, at Abarca, we say it’s about time.
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This blog post was written by Francina Bonnelly Pharm D, Associate Director of Clinical Product & Services at Abarca.
1. On May 16, 2019, CMS issued the Medicare Advantage and Part D Drug Pricing Final Rule (CMS-4180-F) that required each Plan D plan adopt one or more RTBTs that are capable of integrating with at least one prescriber’s ePrescribing system or electronic health record (EHR), no later than January 1, 2021.
2. The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (Pub. L 115-271), referred to as the “SUPPORT Act,” was enacted on October 24, 2018. Section 6062 amended section 1860D-4(e)(2) of the Act to require adopting the Part D e-Prescribing program’s transactions standards to ensure secure ePA request and response transactions between prescribers and Part D plan sponsors no later than January 1, 2021.