Why do we need the new prescription benefit tool?
Prescription drugs are the leading contributor to rising health care costs, but that challenge impacts more than just the financials. One in three Coloradans either cannot fill a prescription, cut pills in half, or skip doses because of the cost.
The Prescriber Tool empowers providers with real-time information on prescription drug costs and affordable alternatives. The goals of the Prescriber Tool are to help improve patient health outcomes and service; reduce administrative burden for prescribers; improve prescription drug affordability for Coloradans, employers and the state; and support providers with value-based payments that reward them for addressing the number one contributor to rising health care costs – rising prescription drug costs.
The following Prescriber Tool affordability functionalities are integrated with numerous electronic health record systems (EHRs):
- Real-Time E-Prescribing: Prescribers can now send prescriptions electronically to pharmacies for Health First Colorado (Colorado Medicaid) patients, increasing convenience and saving time for patients, prescribers and pharmacies.
- Real-Time Benefits Inquiry: Prescribers now have rapid insight into preferred medications from the Colorado Medicaid Preferred Drug List (PDL), empowering them with drug affordability and cost options at the point of care.
- Real-Time Prior Authorization: Prescribers can now get rapid prior authorizations, reducing workload and avoiding manual entry, forms, faxes, lists, and rework.
Enabled for both your Health First Colorado (Colorado’s Medicaid program) and commercially covered patients, the Prescriber Tool reduces rework and administrative burden for providers by enabling e-Prescribing and e-Prior Authorization while improving convenience for patients, too.
Who is the tool designed to be used by?
The tool is designed to be used by prescribers. Our intention is to reward prescribers for using the tool and generating savings. We are currently developing an alternative payment model (APM). Please refer to the Prescriber Tool Alternative Payment Model website for updates.
Are Hospitals as part of the Hospital Transformation Program (HTP) required to adopt the Prescriber Tool affordability module?
Adoption of the Prescriber Tool affordability module is a statewide effort under the Hospital Transformation Program (HTP), and all hospitals are expected to implement and use the tool.
For non-hospital providers, are there incentives to adopt the Prescriber Tool affordability module?
Yes - Please refer to the Prescriber Tool Alternative Payment Model website for updates and eligibility.
Does the tool take away prescriber clinical decision-making?
No. The Prescriber Tool provides pharmacy benefit information and is not a clinical decision-making tool. The prescriber is empowered with options and information but is still the ultimate decision-maker. Regardless of what the prescriber decides, the workflow is easier, rapid, and saves the prescriber time.
How does a prescriber access the real-time prescription benefit tool?
The Prescriber Tool, real-time benefits inquiry module is accessible through compatible EHRs. Please contact your IT Support Staff, EHR Training Team, or EHR vendor to access the tool and get training and education materials. No additional web-link or sign-on is needed within your EHR to access the Prescriber Tool.
What is the tool called in my EHR?
“Real-Time Prescription Benefit” or “Real-Time Benefit Check.” This would apply to all EHRs and may vary by individual EHR vendor.
Is my EHR compatible with the tool?
Prescriber Tool is connected through Surescripts, with approximately 100 EHRs, including: Epic, Cerner, AllScripts, NextGen, Athena, Aprima, AdvancedMD, Greenway, Medisoft, MicroMD, CPSI Evident, and more. To check for your EHR’s compatibility, please go to Surescripts.
My EHR is compatible; how do I ensure this functionality is working?
Please contact your EHR vendor to enable this functionality, if it is not already in place (meaning that prescribers are receiving alternate medications, not just the ability to e-Prescribe or work through a prior authorization). Please ask your EHR vendor to make sure they have turned on or enabled the “Real-Time Prescription Benefit” or “Real-Time Benefit Check” and are routing Health First Colorado (Colorado Medicaid) transactions.
My EHR is not compatible with the tool; what do I do?
Please contact your EHR vendor to request they take steps to establish compatibility and enable the “Real-Time Prescription Benefit” or “Real-Time Benefit Check.” If you need help with installation:
- FY 2021 American Rescue Plan Funding for Health Centers (H8F) Activities and Allowable Uses of Funds: Maintaining and Increasing Capacity - Electronic Health Record (EHR) and Purchase or upgrade an EHR that is certified by the Office of the National Coordinator for Health Information Technology.
- Colorado’s HTP rural hospital support funding allowable uses include
technology infrastructure with payments starting August 2021.
How do I use the tool? Is there training or orientation?
At a high level, the workflow is: (1) during the office visit, queue up medications for prescribing and input the patient’s pharmacy; (2) in the patient chart, verify pharmacy benefits with a primary coverage indicated; (3) coverage and preferred medication alternatives are listed in order of lowest cost; and (4) discuss with the patient and decide which medication to prescribe.
The EHRs that do have this solution enabled have the training and education materials to provide you. Please contact your IT Support Staff, EHR Training Team or EHR vendor to access the tool and get training and education materials.
Each EHR is different, but generally, for most EHRs, when you enable your e-prescription, the functions of the tool will automatically flow.
- Please be careful not to bypass the tool functions.
- For some EHRs, you may need to click to view preferred alternatives. This reduces the need for memorizing preferred medications or utilizing other resources for drug selection, such as looking up the preferred drug list.
- For some EHRs, you may need to check the "do not substitute" block in an EHR when using the tool; this may come up when the less affordable option is a brand name drug versus a generic.
How much time does it take to use the tool in a visit?
It is very efficient and quick. While this will vary depending on the EHR, we hear that it takes seconds or minutes to use. The number of clicks depends on the EHR used.
Is the tool free? What costs are associated with using the tool?
Though EHRs vary, there should not be a "click charge" for using the tool. The payers, such as Medicaid, pay for the usage.
How long does it take to get Prior Authorization Requests (PARs)?
Electronic Prior Authorization will prompt the prescriber for needed PAR information. If the member is eligible for the PAR, then it may be approved within seconds or minutes. If additional clarification is needed, a fax is answered and responded to within 24 hours.
Is the tool turned on for inpatient services?
If a patient is being discharged with prescriptions that are being sent to a retail or outpatient pharmacy and the prescriber and the pharmacy are within the Colorado network, the tool will work. However, the tool will not be engaged for inpatient prescriptions.
How does the tool work for 340B pharmacies?
Colorado Medicaid does not have access to 340B costs, so the tool would function exactly the same as it does for any other prescription.
Are FQHC 340B pharmacies enrolled into the tool?
Yes, all enrolled pharmacy providers are loaded into the tool.
Which payors does the tool support?
The tool returns pharmacy benefit information for all Health First Colorado (Colorado’s Medicaid program) fee-for-service patients. The tool has already been in place for many Commercial carrier patients (e.g., Cigna, CVS-Aetna, Anthem, United), many Connect for Health Colorado patients and some patients with private Medicare Advantage plans.
What if the patient is not insured/self-pay or on sliding fee scale arrangements?
The tool does not return information for uninsured or self-pay patients.
What about dually eligible Medicare-Medicaid patients?
For outpatient pharmacy, most drugs will be covered by Medicare as the primary source of insurance for dually covered patients. CMS has required Medicare to provide a similar capability for Medicare patients. You should be able to see coverage for Medicare, and if needed, for Medicaid, as well. The tool is programmed to turn on for patients whose primary source of insurance is Health First Colorado (Colorado’s Medicaid program).
How does the tool confirm patient eligibility?
The tool confirms patient eligibility with the Pharmacy Benefit Management System (PBMS) at the point of prescribing, in the same way a pharmacy claim would be handled. It does not use or replace your front office workflow. Colorado Medicaid patient eligibility is updated daily.
There are multiple preferred medications shown – how do I know which one is the lowest cost?
For Health First Colorado (Colorado’s Medicaid program), the tool is devised to show alternative medications listed with the lowest cost drug on top (first). Drugs should be shown by hierarchy of lower to higher cost alternatives. Colorado Medicaid copays are $0. The three alternate prescriptions suggested in the tool are based on what is most affordable to Colorado’s Medicaid program. Colorado Medicaid net costs for brand name drugs are similar to 340B pricing. That means, sometimes a brand name drug may actually be less expensive to Colorado Medicaid than the generic substitute.
What are the costs that are shown mean? Will these costs print out on the after visit summary and be the correct co-pay amount?
EHRs only show member co-pay amounts, which for Colorado Medicaid, are $0. The tool is designed to list preferred alternatives in order of lowest to highest cost to Colorado Medicaid. Selecting any of the alternatives offered will save Colorado and taxpayers money, and help us battle the rising cost of prescription drugs.
If my organization has risk-based arrangements with other payors, will this tool help?
Yes, if the payor is integrated with the tool, which many are, it will help. Colorado Medicaid will also be sharing savings with providers to incentivize the use of the tool.
What are the legalities related to this tool and information sharing and use? Are new data sharing agreements needed?
No, nothing new is needed because the tool is integrated within your EHR. The tool provides pharmacy benefit information to prescribers and is NOT a clinical decision making tool.
Are practices or providers able to access any reporting about their use of the tool?
HCPF anticipates receiving reporting and is working on how it might be able to share results related to the value-based payment programs in the future.
Why use e-prescribing?
Electronic prescribing is technology that enables prescribers to write and send prescriptions to a participating pharmacy directly and electronically instead of writing, faxing, or calling in prescriptions. Information regarding member eligibility, formulary, and medication history are passed back to the provider to support their e-prescribing effort. The eRx technology enables secure, bidirectional, electronic connectivity between physician practices, through their electronic health records (EHR), e-prescribing subcontractor and pharmacies.
- How it works:
- Offers the patient pharmacy benefit eligibility and coverage information
- Conveys the e-prescribing vendor supporting data needed to establish the identity of members across different pharmacy benefit managers
- Delivers the prescriber a list of prescriptions dispensed to patient
- Provides the prescriber a list of medications “on formulary” for the patient
- Key Advantages: e-prescribing provides the following potential benefits:
- Improved legibility of prescriptions with reduced variation in the quality of prescribing
- Fewer number of lost prescriptions and prescribing errors thus reducing potential adverse drug events
- Shorter wait times for patients collecting their medications from pharmacies
- Better monitoring of controlled substance prescriptions to prevent doctor shopping and over-prescribing
- Reduced drug costs through increased formulary compliance
- Faster medication reconciliation process by automatically being able to search patient prescription history
- Improved quality and better patient experience because the right medication was filled the first time
- Reduced time spent by staff managing prescriptions by phone or fax and responding to refill requests
Prescribers can now send prescriptions electronically to pharmacies for Health First Colorado members, increasing convenience and saving time for patients, prescribers and pharmacies.
Why use Real-Time Benefits Inquiry?
The Real-Time Benefits Inquiry (RTBI) provides accurate and actionable information in the EHR to the prescriber to use before they prescribe a medication and before the patient goes to the pharmacy. The Real-Time Benefits Inquiry reduces time and effort to help patients get the right medication.
- How it works:
- Integrated into EHRs, prescribers can view patient-specific information about confirmation of coverage, preferred cost effective alternatives, and prior authorization alerts — providing actionable intelligence when and where physicians need it most
- The pharmacy benefit manager can send information to the physician via a real-time data exchange in their EHR
- With this patient-specific information, physicians can have more informed conversations with patients, leading to decisions that align with the patient’s clinical needs and plan benefits, and can reduce the cost of care
- Sharing relevant information exactly when physicians need it helps to reduce costs, increase efficiencies, and improve adherence and outcomes for patient
- Key Advantages:
- Informing prescribers about lower cost options
- Reducing unnecessary or avoidable prior authorization
- Improving adherence to therapy and overall formulary compliance
- Informing doctors about a patient-level benefit at the point of prescribing
Prescribers now have rapid insight into preferred medications from the Colorado Medicaid Preferred Drug List (PDL), empowering them with drug affordability and cost options at the point of care.
Why use Electronic Prior Authorization?
Electronic prior authorization enables a prescribing physician the ability to submit a Prior Authorization electronically in near real-time. Electronic prior authorization services use the CoverMyMeds® web application, the nation’s leader in electronic prior authorization.
- How it works:
- Processes requests for any medication
- Receives faster prior authorizations determinations, often in real time
- Creates prior authorization renewals from previously submitted requests
- Providers incur no costs
- Key Advantages:
- Largest Network: Encompasses the nation’s largest electronic prior authorization network with 700,000+ providers, 49,000+ pharmacies, 500+ electronic heath record systems (EHRs) and payers representing 75% of U.S. prescription volume.
- HIPAA Compliant: Employs a set of policies and procedures, with technical, physical, and administrative safeguards to maintain compliance with the HIPAA Privacy Rule and its implementing regulations.
- NCPDP Elite Partner: Collaborates with NCPDP and applies the NCPDP SCRIPT Standards to all ePA transactions.
- Industry Expert: Publishes an annual ePA Adoption Scorecard which includes a deep dive into the ePA landscape, ePA legislation and industry trends.
- Top-Tier Support: Utilizes a team of PA experts that offer real-time responses via phone or live chat. No phone tree, no waiting—real people ready to help.
- Bypasses the need for providers to perform a separate submission of the prior authorization request.
Prescribers can now get rapid prior authorizations, reducing workload and avoiding manual entry, forms, faxes, lists and rework.
How much time will use of the Prescriber Tool add to my workflow?
The Prescriber Tool is efficient and quick. While this will vary depending on the EHR, we hear that it takes only minutes or less to use. The number of clicks depends on the EHR used.
Does the Tool use a single sign-on?
The tool is accessible within the EHR without additional sign-on.
Does the prescriber have to go through the Prescriber Tool every time he/she needs to write a new prescription, even if just to a new pharmacy?
Yes, prescribers will need to follow the same workflow for each prescription.
Does the Prescriber Tool require me to go to a different place in order to write prescriptions for Medicaid patients?
No, the workflow within your EHR will be the same as for your patients covered under commercial insurance.
Does the Tool auto-complete PAs so that the staff is not burdened with filling them out?
While the Prescriber Tool does not automatically complete the entire PA form, some fields will auto-complete. The amount of information that is populated will depend on the EHR system.
Can I see a demo of the Prescriber Tool?
We have an informational presentation on the Prescriber Tool that HCPF can provide. Demos are completed with providers in their own EHR's.
How does the Prescriber Tool work for different insurances?
The Prescriber Tool populates member insurance information when the insurance information is selected. The provider work-flow should be the same for Colorado Medicaid and commercial insurance plans.
Do providers need to use different Prescriber Tools?
If your EHR system is integrated with Surescripts then you should not have to use a different prescriber tool.
What happens if the prescriber writes a prescription for a patient that is not seen?
As long as the prescriber is following the same EHR work-flow and initiates the e-prescribing and real-time benefit check process, it should result in the same outcome as a patient being seen in office.
Does the Tool integrate well with EPIC?
Yes, the Prescriber Tool is integrated with EPIC. EPIC released an update in February 2022 so providers can see drug alternatives provided through the real-time benefit inquiry for Colorado Medicaid members.
Have sufficient HIPAA security controls, privacy settings, and business agreements been built into the Tool?
Yes, privacy and security are being managed by the EHR vendors in coordination with the Department vendors.