Rcopia Formulary Explained

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Description

A Formulary is somewhat like a pre-d or pre-auth for prescriptions.

Steps

There are various codes that indicate the level of coverage by a patient's Insurance. Likely this will be a medical coverage as this is likely what they have used recently to fill a prescription and unless they have had major work done, they may not have used their dental insurance. The DrFirst formulary system loads and displays data that indicate whether a given drug is covered by a given patient's insurance, and what restrictions apply. Rcopia determines this by cross-referencing two sets of data, eligibility information and formulary information.

Insurance payors create Formulary Files, each of which is a list of drugs with some 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 off of patient information that is available.  Curve sends:

• First Name
• Last Name
• Zip Code
• Home Phone
• Date of Birth
• Gender (sex)

This information makes it so that Surescripts then pulls in the forumlary based on what insurance coverage they have.

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: 

1. Rcopia makes an eligibility request to the Payor Engine using the patient's demographics.
2. 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 (or partner system) selects one to use for formulary checking.
3. Rcopia looks up the drug against the formulary file data for each formulary ID in the benefit.
4. Rcopia combines and then displays the aggregated formulary codes.

NOTE: Hovering over a code, will show you a brief description.