CMS Medicare Rule for 2023: Is Your Beneficiary RTBT Program Ready?

Implementing real-time benefit for beneficiaries will soon be a compliance necessity for Part D health plans. Medicare Part D beneficiaries will have access to real-time drug transparency as part of the new CMS Beneficiary Real Time Benefit Tool (RTBT) rule (§ 423.128)[i]. This rule finalizes regulations requiring Part D plan sponsors to implement a beneficiary real-time benefit tool by January 1, 2023.

Why do we need more transparency?

Prescription abandonment and non-adherence are two outcomes that can lead to progressively worse health or risk of further health complications for the individual patient, as evidenced in these examples:

• Prescribing a high-cost medication can lead to prescription abandonment when patients cannot afford the prescribed medication.
• When patients don’t understand either the utilization requirements or potential side-effects, there is a greater probability for non-adherence.
• Patients may have influence from friends or family that are taking a particular medication and may not understand why they are not prescribed the same drug, again leading to non-adherence.

The new beneficiary rule addresses these concerns with more consumer transparency into price and alternative medications.  This visibility into lower-cost alternatives enables the provider to pair clinical judgement with actual patient cost, so they can evaluate clinically equivalent drugs in a more proactive way.  

When this information is available at the point of care, providers can communicate face-to-face with patients about the benefits of the recommended drug, any potential side effects and the importance of adherence, while also facilitating a discussion about cost and the patient’s ability to pay for the medication.[ii]  The patient can then understand not only what they will pay at the pharmacy, but also the reasoning behind a specific medication, and why they should take it as prescribed.

Conversations that include price transparency and alternate clinically-viable medications empower patients to ask questions and feel a part of the decision making process. These discussion foster trust and relationship-building between patients and providers, a proven association for positive functional health.[iii]

How do we get there?

Technology can solve for details on specific drugs like dosage, application, outcomes and side effects for clinical viability. That information can be combined with prescription insurance coverage for the patient to get actual cost at the pharmacy. Providers are a key part of the equation, combining all of this information with their knowledge of the patient’s previous medication usage and understanding of patient history and preferences.

The results are worth it. Giving consumers visibility into provider-recommended prescription alternatives along with actual out of pocket cost drives a more thorough medication conversation between the provider and patient.

The new CMS rule facilitates these conversation by making consumer transparency a requirement. This enables them to take part in the decision, understand available alternatives and eliminate surprise costs at the pharmacy, all of which can improve adherence while realizing cost-savings for the health plan.^[iv]

Heads up – plan now for the upcoming January deadline

With a looming 1/1/23 deadline, health plans will need to determine their technology solution quickly to comply. According to the mandate, whatever technology a health plan chooses must allow enrollees to view the information included in the prescriber RTBT system, which will include accurate, timely, and clinically appropriate, patient-specific real-time formulary and benefit information (including cost, formulary alternatives and utilization management requirements).  

SS&C Health clients are already using our Real-Time Benefit service to deliver point-of-care drug price transparency to their providers, with visibility into comprehensive information integrated directly into the EHR workflow, as recommended for provider adoption. With our solution, clients can validate actual influenced savings on pharmacy claims to make decisions based on substantiated results instead of relying on projections.

Read our "Increasing Therapeutic Visibility for Providers" case study to find out how one client implemented our provider RTB solution and realized $260K to $310K in quarterly savings, increased provider adoption, and better served their members.