A Formulary is somewhat like a pre-d or pre-auth for prescriptions.
There are various codes that indicate the level of coverage by a patient's insurance. Likely this will be medical coverage, as this is likely what they have used recently to fill a prescription; unless they have had major work done, they may not have used their dental insurance.
All Rcopia 4 users have formulary checking enabled. Formulary information in Rcopia 4 is obtained from Surescripts.
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When you select a patient, Rcopia 4 will automatically search for his or her eligibility using the patient’s first and last name, ZIP code, and DOB.
Please Note: Surescripts provides formulary information from health plans, Pharmacy Benefit Managers, and Payers such as Blue Cross, Anthem, MAMSI, etc. Surescripts may not provide eligibility for all government-funded formularies such as Medicaid or some small regional payers.
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If you try to prescribe a medication that is not covered, or has a higher co-pay, you will receive a formulary alert in the system.
Insurance payors create Formulary Files, each of which is a list of drugs with data indicating how well the drug is covered. Formulary files are provided to DrFirst by Surescripts. Each file is associated with a Formulary ID.
The information is pulled in automatically based on patient information that is available. Curve sends:
- First Name
- Last Name
- Zip Code
- Home Phone
- Date of Birth
- Gender (sex)
This information allows Surescripts to pull in the formulary based on the patient's insurance coverage.
When a drug is prescribed for a patient, Rcopia displays a set of Formulary Codes indicating how well that drug is reimbursed for that patient, as follows:
- Rcopia makes an eligibility request to the Payor Engine using the patient's demographics.
- The Payor Engine returns zero or more Drug Benefits, one for each insurance plan that covers the patient. If there is more than one benefit, the user selects one to use for formulary checking.
- Rcopia looks up the drug against the formulary file data for each formulary ID in the benefit.
- Rcopia combines and then displays the aggregated formulary codes.
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