The New Standard for Electronic Benefit Verification

Forget “industry standard.” Electronic Benefit Verification sets a new standard.

Once the provider has chosen a therapy to treat the patient, in many instances, life sciences companies offer programs to help patients access and stay on therapy, especially those who are uninsured or underinsured. But first the patient’s pharmacy benefits must be verified, and that involves an antiquated, manual process.

The outdated process used by life sciences companies and patient access vendors can take hours or days of back-and-forth phone calls, faxes and paperwork just to determine if a medication is covered, its cost, and whether prior authorization is needed.

Meanwhile, the patient doesn’t have their medication, even though they may rely on it. What if the process took just seconds, without any paperwork or phone calls?

Let’s look at what that might mean for patients with cystic fibrosis (CF).

The Old Standard: Waiting for Days

CF is a genetic condition that can affect the lungs and make it hard to breathe, among other systemic issues. It can cause frequent lung infections like pneumonia and bronchitis, especially if the condition goes un- or under-treated. CF often has a dramatic impact on a person’s life.

Recent pharmaceutical innovations in the form of CFTR modulators have transformed care for CF patients, significantly improving their quality of life, but patients generally need continuous access to these therapies to manage the condition. Any interruption in treatment could have severe consequences for their health.

The need to re-verify and reauthorize due to a patient changing insurance plans is one such interruption.

And since prior authorizations often impose a time limit—a few months or a year, for example—verification and reauthorization may be required to confirm that treatment continues to be medically necessary, the patient is responding to it, and the medication itself is still covered by insurance.

CF patients who depend on medication to maintain lung function may not know that their medication is no longer covered; that is, until they go to the pharmacy to pick it up. Now they must go without treatment while waiting for the paperwork to be done, with the possibility of a significant decline in their health.

These patients rely on their medications. They really can’t wait.

The New Standard: Near-Instant Verification

Surescripts Electronic Benefit Verification is transforming how patient access teams verify pharmacy benefits. It’s the only solution that uses a single, direct connection to pharmacy benefit managers (PBMs) across the nation to deliver real-time, patient-specific benefit information.

It doesn’t rely on AI-generated estimates. It doesn’t rely on past claims data.

The solution delivers actual benefit information straight from the source. That means no guesswork, no delays, and no need for the patient’s Social Security number. And the information is delivered to the patient access program in seconds.

Verification includes:

• Coverage status (covered, not covered, or covered with restrictions)
• Estimated out-of-pocket costs
• Deductible status
• Prior authorization requirements
• Primary and secondary coverage details

In short, Electronic Benefit Verification eliminates the need for manual outreach to payers.

For patients, this means they get the care they need faster and easier. For care managers at health plans, it means an improved experience for members. For patient access companies, it means patients benefit from life-changing pharmaceutical innovation. Everyone wins.

Electronic Benefit Verification is the opposite of reactive. It’s the very definition of a proactive approach.

It sets a new standard.