Co-Authored by Jennifer Young and Roxanne Newland
The real-time drug benefit comparison tool (also known as RTBT) was proposed by CMS in 2019 and delayed due to industry concerns. In the January 19, 2021 final rule, Medicare Part D drug plans will be required to offer a RTBT effective January 1, 2023. According to CMS, compliance with the final rule requires health plans use a RTBT that includes (1) patient-specific utilization requirements (e.g., Prior Authorization, Step Therapy Requirements, and Quantity Limits); and (2) patient out-of-pocket costs at the patient’s selected pharmacy. Part D plans must ensure that the vendor that they select provides an accurate, timely, clinically appropriate, beneficiary-specific, and real-time formulary tool. The goal of the regulation is to give enrollees the ability to research cost sharing and utilization management requirements for their prescription drugs, including potential lower cost alternative therapies to specific prescribed drugs. CMS also anticipates that utilizing a RTBT will help to improve medication adherence since 30% of prescriptions do not get filled by patients partly due to cost.
The final rule is aimed at members, when, in reality, health plans need to ensure these tools are actively and widely used by the providers who prescribe drugs.
Let’s review the typical flow: A member is seen in the provider office and provided a script, which is then taken to the pharmacy to fill. Only, once the member is at the pharmacy, they realize the pharmacy copayment is too high. In this scenario, the member may then look for an alternative drug that is at a lower cost. So, in today’s process, the member would make additional calls to the provider office for help, ask the pharmacist for advice or place a call to the health plan, which may lead to a coverage determination request, a potential grievance on the cost share amount or a tiering exception request. Under the new rule, health plan customer service representatives will need access to the RTBT to advise on alternative drugs and pricing for that member, but who will not be able to speak to potential side effects, allergies and contraindications the member may have for those alternatives. Ultimately the member must still work through possible alternatives with their provider.
A health plan’s objective should be to create the greatest value to this regulation and create member satisfaction with a process that is logical, efficient, and effective. To do this, health plans must consider the value of provider education and incentive programs. This is easier said than done. As industry experts, we know there is also a great deal of potential infrastructure that must be put into place to be compliant with this rule, while looking for ways to maximize the investment dollars.
Here’s where we recommend you start:
Contact your current vendors, particularly you PBM or EHR vendor, on RTBT vendors or any add-on functionality they may have available.
Research and evaluate RTBT vendors for compliance with CMS regulations, usability and implementation approach, cost and timing.
Evaluate how to integrate the RTBT into your provider and member portals.
Evaluate how to make the tool available to your member and provider call centers.
Evaluate CMS’ proposal for health plans to offer rewards and incentives for members that use the RTBT.
Evaluate how to offer bonus payments or incentives for providers that use the RTBT.
Create your implementation plan that includes a communication and training plan for providers, members and customer service staff.
When should you start?
Starting now will ensure that you are fully compliant with the RTBT regulations for January 2023. Fortunately, there are plenty of existing Rx decision support platforms on the market, but health plans must account for the contracting and implementation timelines, as well as the unknowns of existing technological infrastructure that may need to be modified to support this implementation. Rebellis Group is staffed with industry experts who can address what impacts these policy changes can have across your operations and provide solid solutions to ensure maximum revenue retention.
firstname.lastname@example.org to see how Rebellis Group can support your organization to comprehensively plan this implementation to maximize your ROI.