- Programs & Services
Member-Specific Benefit Information Across All Points of Care
November 28, 2017
Executive Vice President and Chief Operating Officer, CVS Health
Not understanding benefits clearly, or facing unexpected, high, out-of-pocket costs can cause patients to not fill a prescription, leading to non-adherence, and ultimately, higher downstream costs. Lack of visibility into drug options, whether at the doctor's office or in a pharmacy, can add to the confusion and create member disruption. What a prescribed drug costs, whether it is covered, and whether a pharmacy is in network, can vary based on the member’s plan design, formulary, and deductible.
|Research shows that members often feel they do not have adequate knowledge about the use of formularies or the drugs covered by their plan.1|
Total Transparency with Real-Time Benefits
To help members have convenient access to affordable medications, CVS Health is launching real-time benefits across all key points of care. For the first time ever, members and their health care providers — prescribers as well as pharmacists — will have transparent access to member-specific information at the point of prescribing and at the pharmacy. Having current, relevant information available in real time will help eliminate potential medication rejects or delays in filling a prescription, and help lower costs for members.
During a Provider Visit
Currently, when a provider is about to write a prescription, the drug coverage information available is directional, and not specific to the member. With real-time benefits, even before a prescription is written, the provider will have member-specific information available at their fingertips, including:
- Cost of a selected drug based on the member’s plan coverage, deductible, and how much of the deductible the member has met
- Up to five clinically appropriate therapeutic alternatives, that may also be lower cost, generated from our database of drug classes, mapped for clinical substitution and specific to the member’s formulary
- Restrictions on the selected drug, such as prior authorization (PA), step therapy requirements, or quantity limits
- Whether the selected pharmacy is in network
With real-time benefits, all of the information is integrated into the e-prescribing workflow, enabling prescribers to make more informed decisions and select a clinically appropriate medication that may be more affordable for the member. If the selected drug has any restrictions, the connected prescribers will also be able to immediately submit an electronic PA (ePA) request, speeding up and simplifying an often onerous process. About 80 percent of physicians think manual PA requests require extra work, rework, and follow-up. Any prescriber using an electronic health record system with real-time benefit and ePA will be able to execute this process seamlessly. Real-time benefits further build on CVS Health’s use of electronic health records, to support MinuteClinic nurse practitioners and CVS Specialty care management programs.
At the Pharmacy
When the member takes a prescription to the pharmacy, our integrated technology will enable the pharmacist to see the same list of clinically appropriate formulary alternatives.
At CVS Pharmacy, the information will be integrated directly into the pharmacist’s workflow, making it easy to engage patients and inform them about potential lower-cost alternatives, based on formulary coverage. If the member’s prescription is for a medication not on formulary, the CVS pharmacist will be able to request a prescription change — when needed — from the provider at the click of a button.
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Beginning in early 2018, as part of CVS Health’s enterprise-wide focus on helping patients saving money, CVS pharmacists will also be able to see the associated out-of-pocket cost for both the prescribed medication, and alternatives on the member’s formulary. This will help ensure alignment with the member's plan design and enable the pharmacist to access the lowest cost medications within the member's benefit. For those members for whom drug costs are still a concern, the CVS pharmacist will also be able to share additional cost savings opportunities such as prescription discounts, when available.
For the Member
Beginning in early 2018, real-time benefit information will be added to the Check Drug Cost tool on Caremark.com, giving the member the ability to find lower-cost alternatives whether the member is at a provider's office, the pharmacy, or any other location. Customer Care representatives will also have this information integrated in their system so they can better assist members with questions about cost and coverage.
Interoperability Across the System
CVS Health is committed to transparency wherever the member is on the health care continuum. Real-time benefits further build on our connections with electronic health records, bringing the system closer to true, seamless interoperability. Increasing connectivity through interoperability, eliminating blind spots, and providing transparent access to information at critical decision points will help members get the medications they need faster, more easily, and affordably, enabling them to be more engaged in their own care and benefits.
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