Real-Time Prescription Benefit for Pharmacy Overview

Surescripts Real-Time Prescription Benefit (RTPB) for pharmacy is a real-time request and response message between the pharmacy and Pharmacy Benefit Manager (PBM). The RTPB message delivers patient-specific medication cost and benefit information to pharmacists. This may include point-in-time estimated cost, alternative medication options, 30-day supply cost, 90-day supply cost, patient out of pocket and deductible information, and coverage alerts.

RTPB data can be referenced before a claim has been adjudicated at the patient’s request or after the claim has been adjudicated if a high copay is returned or if the pharmacist wishes to avoid prior authorization.

RTPB provides value by saving pharmacy staff time, increasing staff and patient satisfaction, lowering health care costs, increasing speed to therapy, and improving health outcomes. By providing accurate, up-to-date, patient-specific information and cost-effective medication options, pharmacists and patients can make informed decisions that reduce payment obstacles and improve medication adherence.

This section includes high-level overviews of how RTPB works within an optimized e-prescribing workflow.

Use cases of RTPB within a typical pharmacy workflow include:

On Demand

A pharmacy runs an RTPB at the patient’s request for any reason.

Proactive

A pharmacy automatically runs RTPB under certain circumstances, such as the following: a copay is over a certain amount, a prescription is rejected because a prior authorization is required or the medication is not covered.

Refills

A pharmacy automatically runs RTPB after processing a claim for the prescription if the copay is above a certain threshold or is returned as drug not covered or prior authorization required.

Surescripts created this document to provide pharmacy customers information needed during implementation of RTPB for pharmacy messages and workflows.

The audience includes any customer responsible for configuring or developing a system interface for the electronic messages.

Please reference the following documents when reading this guide:

NCPDP SCRIPT

This guide utilizes the NCPDP (National Council for Prescription Drug Programs) messaging standard Prescriber/Pharmacist Interface SCRIPT version 2023011 as a baseline. To become an NCPDP member, please go to https://www.ncpdp.org/Membership.aspx.

The NCPDP SCRIPT Standard 2023011 package contains a complete list of fields and additional requirements. Customers should read and comprehend the associated standards prior to reading this guide.

NCPDP is an American National Standards Institute (ANSI) accredited Standard Development Organization. The NCPDP “SCRIPT” standard is a copyrighted document and may be obtained by contacting:

NCPDP 9240 E. Raintree Drive Scottsdale, AZ 85260-7518 Phone: (480) 477-1000 Fax: (480) 767-1042 https://www.ncpdp.org