Check Patient Benefits
RxLightning’s Check Patient Benefits Functionality
What is Check Patient Benefits:
The Check Patient Benefits functionality was designed to help providers and care teams efficiently assess pharmacy benefit coverage for their patients.
The tool provides a comprehensive list of pharmacy destinations, estimated patient pay amounts, and any associated restrictions (e.g., prior authorization required).
Enabling Informed Decision Making:
Check Patient Benefit’s primary goal is to offer real-time transparency into patient pharmacy benefit coverage, empowering prescribers to:
Make well-informed destination choices, sending the script to the most appropriate pharmacy the first time (mitigate triaging).
Have pricing conversations with their patients, providing them with the most affordable pharmacy option and driving medication adherence.
Simplified Benefit Checks:
This functionality simplifies the benefit check process by simultaneously assessing all limited distribution drug (LDD) pharmacies in a single step, eliminating the need for multiple real- time benefit checks (i.e., 1 check per pharmacy).
Transparent and Actionable Results:
Results generated categorize pharmacies by: covered, covered with restrictions, or not covered.
Results display alerts for various restrictions, including prior authorization requirements, step
therapy, and/or quantity limits.
Results display patient estimated out-of-pocket cost information, to provide transparency for
financial considerations.
Additional Notes:
Eligibility Check must run successfully in the Patient Profile before starting Check Patient Benefits.
This functionality will not work if insurance information has been entered manually.
This functionality is tailored for patients with pharmacy coverage through Pharmacy Benefit
Managers (PBM) within the RxLightning network. Unfortunately, not every patient will have insurance details or coverage within the network, but we are continuing to work with partners to expand our coverage and deliver actionable data as frequently as possible.
Steps to use Check Patient Benefits:
On the Start A New Enrollment screen, choose the Patient Name, Prescriber, and Drug from the drop-down menus.
Choose the Primary Insurance under the Patient Name.
Choose Check Patient Benefits in the Destination drop down menu.
The Quantity and Days Supply fields will auto-populate.
Click the blue Start button.
The pharmacy, coverage, and cost results will populate.
Review the results and start the Enrollment or Prior Authorization directly from the results page.
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