Three Factors to Determine the Best e-Support Services Provider for Your Brand

Today’s guest post comes from Stacey Little, Senior Vice President of Business Development and Marketing at AssistRx.

Stacey discusses how a patient support vendor can help specialty pharmacy patients attain prior authorizations and access critical therapies. She offers three criteria that manufacturers can use to evaluate e-support services providers.

Learn more about AssistRx’s technology and patient support services by viewing their on-demand webinars.

Read on for Stacey’s insights.

Three Factors to Determine the Best e-Support Services Provider for Your Brand
By: Stacey Little, Senior Vice President of Business Development and Marketing, AssistRx

Improving access to therapy is critical to life sciences companies and the vendors supporting them. Understanding payer coverage and access restrictions by product and health plan can be challenging and time-consuming—especially for specialty therapies.

Limited visibility into patient coverage slows or even prevents specialty therapy initiation. Currently, the industry standard for patient specialty therapy initiation is 14-20 days. Further, 92% of physicians say that prior authorizations (PAs) have a negative impact on patient clinical outcomes, and two-thirds of healthcare providers (HCPs) admitted to refraining from prescribing medication due to PA requirements.

Life sciences companies, therefore, seek patient support vendors that deliver e-coverage and e-PA solutions in an accurate, real-time and far-reaching fashion. They want HCPs to gain comprehensive coverage knowledge at the most important part of the therapy journey—the point of care.

Here are three questions to help you choose an e-support services vendor that will deliver the highest speed, accuracy and visibility:

1. WHAT METHOD ARE YOU USING TO POWER E-COVERAGE?

Many methods are used to pull patient benefit coverage, including artificial intelligence (AI), machine learning (ML) and API integrations. Each has pros and cons.

• AI: The theory and development of computer systems able to perform tasks that normally require human intelligence.
• Automates repetitive tasks, identifies and predicts trends and creates personalized communications; however, predictions are based on historical data, personalization does not account for patient lifeflow and HCP workflow and many systems are misrepresented as AI.
• ML: Computer algorithms that improve automatically through ingestion of more data. ML builds models based on sample data to make predictions/decisions without being programmed to do so.
• Also automates repetitive tasks and identifies and predicts trends, but “learn as you go” model requires high quantity and quality of data. Additionally, ML creates a “black box” issue and multiple scenarios at risk for bias.
• API Integrations: Connections between two or more applications that exchange data between each other through APIs by working off code between software programs.
• Facilitates real-time, accurate data exchanges between multiple stakeholders without requiring predictive modeling or ingestion of data over time. Yet, this solution requires secure API gateway technology and is highly complex.

2. HOW RELIABLE IS YOUR E-COVERAGE TECHNOLOGY?

Vendors usually leverage one of three options to return patient benefit information:

• Pharmacy Test Claims: Confirms patient eligibility and existence of coverage restrictions and/or requirements. Yet, limitations include:
• Requires comprehensive patient insurance information
• Generally does not provide in-network pharmacy details, plan type, coverage restrictions and PA requirements
• Returns can be deceiving (NDC not covered can mean PA required)
• If a restriction is identified, will not provide coverage and out-of-pocket amounts
• Can only be run for the pharmacy system processing the claim for the quantity in the prescription
• Only obtains coverage for a single pharmacy

• Standard e-Benefit Verification (e-BV): Provides expanded data, such as coverage status and cost shares; however, limitations include:
• Only provides data for covered patients through a small number of PBMs; leaving 10M+ lives out of scope
• Does not include plan type, hindering differentiation of commercial and government coverage
• Often returns "Not Covered" when a PA is required and unfulfilled
• Displays alternative products, but does not factor in the patient's medical history or actual cost if the patient qualifies for financial assistance programs

• Advanced Benefit Verification (ABV): Requires only five patient identifiers (e.g., first, last, date of birth, gender and zip) to pull results in under 30 seconds. Additional features:
• Patient benefit includes coverage, patient specific restrictions, estimated cost at requested pharmacy and plan preferred (e.g., direct mail)
• Patient’s information is updated with the name the PBM has on file
• Drug details are related to the response (e.g., strength, dose form)
• PBM information includes PBM ID, BIN/PCN/group, card ID, relationship and effective/term dates
• Plan information includes plan name, type, channel, copay card eligibility and employer
• Formulary includes status, restrictions, step, quantity, age restriction and PA requirements
• Includes monitoring and reporting to improve ongoing price transparency and informed decision making

For medical benefit products, vendors leverage either manual BVs or e-Medical BV (e-MedBV). Medical benefit coverage has lower visibility and relies on J-codes, which do not identify the manufacturer, strength or package size. Additionally, J-codes may not be assigned until 18 months post-launch. Medical benefit information is not as robust as pharmacy benefit information, and the industry standard return is roughly 30% of payer-covered lives.

However, a network of medical benefit service partners facilitates greater access to coverage information. AssistRx’s e-MedBV solution, for example, returns nearly 50% more payer-covered lives at a higher accuracy rate than industry standard by leveraging multiple data sources. In under 30 seconds e-MedBV delivers:

• Plan, payer, type, member ID, group ID and effective/termination dates
• Individual/Family deductibles year to date, per year and remaining
• Individual/Family out-of-pocket cost year to date, per year and remaining

3. HOW EXTENSIVE IS YOUR PAYER REACH AND WHAT LEVEL OF DETAIL CAN YOU PROVIDE?

The element that differentiates e-coverage solutions providers is data required, payer reach, turnaround time, and return specificity and accuracy. The right vendor can deliver on these differentiators and be interoperable enough to meet HCPs in their workflows.

By selecting an e-coverage solutions partner with multiple data sources, wide payer connectivity and proprietary algorithms to rapidly return comprehensive, accurate results in real time, manufacturers support HCPs at the most critical point in the patient journey to initiate the most beneficial therapy for their patients.

Learn more about AssistRx’s technology and patient support services by viewing our on-demand webinars.

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