Medication not covered.
Translation: Are you prescribing something the patient can afford?
This flag is the primary reason real-time prescription benefit solutions were developed—to help providers know if a medication is covered or not covered. Providers aren’t walking encyclopedias who have catalogued every patient’s specific plan details. An RTPB tool reduces friction at the point of prescribing by offering a provider comprehensive options of what medications are covered for the patient. Having real-time pharmacy pricing for the chosen drug and on-formulary alternatives at the point of care helps providers make informed decisions with their patients.
Refill too soon.
Translation: The patient should still have some quantity of medication left from the last order.
Did the patient lose her medication? Is she taking it as instructed? This flag is a great conversation starter for a provider to dig into a patient’s adherence and understanding of how she is supposed to take the medication.
In 2021, RxRevu’s “Refill too soon” coverage alert resulted in providers suspending the order 52% of the time; when providers have the right information at the point of care, they can provide a better experience by ensuring patients don’t waste time at the pharmacy trying to get a refill.
Prior authorization required.
Translation: Considering another therapy will save you time and reduce your care team’s workload.
This is the number-one flag we see populate in our real-time benefit check tool. On average, it takes about 15 minutes to process a simple medication and 60 minutes to process a complex medication prior authorization. That doesn’t account for all the back-and-forth between a patient and their care team. The unfortunate truth is that prior authorizations can delay patient care up to three weeks. This alert enables care teams to proactively view medication options without PA requirements, reducing their downstream workload and increasing patient access to care.
Supply or Quantity Limit exceeded.
Translation: Does the duration of this therapy make sense, or is the quantity too high?
We typically see this flag with medications that are ordered “as-needed” (e.g., PRN) or for acute therapies, such as inhalers or migraine medications. If a patient has too much of a therapy or is excessively using the medication, that can indicate there might be something else wrong. Reassessment of the patient’s condition will ultimately lead to better overall patient health.
What Red Flags Really Mean
When a red flag presents itself in a relationship, it doesn’t mean you have to give up dating altogether—it just means there are better options out there. The same goes with red flags a.k.a. coverage alerts in the EHR; they give providers the opportunity to change prescribing behavior and improve a patient’s access to care.
RxRevu has built the industry’s most robust payer/PBM network, bringing accurate coverage information on more than 150 million patients to health systems and hospitals across the country. We pride ourselves on getting the most helpful alerts to the prescribing workflow so providers can make the most informed decisions with their patients.
If you’re utilizing Epic’s EHR, learn more about our integrated solution and how it can be implemented at your health system. Cerner and athenahealth EHR users can learn more about how we’re already bringing benefit information into their workflows.