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Set Up Pharmacy Benefits Verification
Gain quick access to patient care and verify benefit coverage details. Patient services representatives can use a streamlined process to assist patients in getting an accurate summary of their pharmacy benefits. Representatives can use a guided flow to initiate a verification request to payers and receive a response for pharmacy coverage details, including coverage status, co-pay, co-insurance, and deductibles.
Required Editions
| Available in: Lightning Experience |
| Available in: Enterprise and Unlimited Editions with Life Sciences Cloud or Health Cloud |
Pharmacy benefits verification plays a crucial role in patient services programs. Verifying patients' benefits is key to improving patient drug access and adherence, and enhances patient outcomes, especially for chronic illnesses. Drug manufacturers, providers, and pharmacies can use the process to promptly prescribe and administer the right medication to patients.
The process of checking real-time pharmacy benefits involves:
Pharmacy Benefits Verification Request
Representatives can use a guided flow to seamlessly verify pharmacy coverage benefits by initiating a verification request for clearing houses or payors. Pharmacy Benefits Verification supports two types of verification requests.
- Electronic Verification Request
- Manual Verification Request
The verification request includes information about the patient, practitioner, drug, and pharmacy. Each request is created for a single member plan, and representatives can generate multiple requests for different drugs under any member plan available for a patient. If the member plan isn’t created for the patient, representatives can easily create member plans directly from a care program enrollee record page.
Pharmacy Benefits Verification Response
For a manual verification request, representatives can manually connect with payors or clearing houses to get detailed coverage information, including coverage status, co-pay, co-insurance, and deductibles. However, for electronic verification requests, Salesforce integrates with the third-party clearing houses or payors through MuleSoft. The clearing houses then further connect with the payors and get the patients' benefit details. This immediate access to accurate benefit summaries helps representatives generate and share benefit packages with patients.
Generate Call Script and Benefit Summary with Einstein Generative AI
To accelerate the verification of pharmacy benefits, representatives can generate an AI-powered call script. This call script includes all the missing coverage fields and plays a key role in getting missing information from payors. Additionally, representatives can also generate a concise summary of the patients’ pharmacy benefits.
- Pharmacy Benefits Verification Data Model
Pharmacy Benefits Verification uses a data model that’s FHIR-CARIN and NCPDP aligned to store the data and make the data model interoperable. - Org Setup for Pharmacy Benefits Verification
Before you use Pharmacy Benefits Verification, you must prepare your org by completing tasks such as assigning permission sets to your users, configuring setup entities, enabling history tracking, and adding picklist values to certain objects. - Benefits Verification Requests
Understand the two types of pharmacy benefits verification requests that your representative can create to verify patients' benefits details. - Data Management for Pharmacy Benefits Verification
To help your users get the most out of the Pharmacy Benefits Verification, configure your org with the necessary data. For patients, admins must set up the data that’s automatically populated in the guided flow. For pharmacies, purchaser plans, member plans, products, care program, and related objects, admins must set up the data that’s further used in creating the verification request. - Add Pharmacy Benefits Verification to the Care Program Enrollee Record Page
Enable case managers to verify the pharmacy benefits coverage details by adding thePharmacyBenefitsVerificationFlexcard to the Care Program Enrollee record page. - Pharmacy Benefits Reverification
Use Pharmacy Benefits Reverification to periodically check a patient's eligibility for pharmacy benefits under their health insurance. Reverification ensures that patients continue to get the right coverage for their prescription medications without any breaks. - Set Up Pharmacy Benefits Verification Flows
Enable your patient service representatives to initiate an electronic verification request on behalf of a care program enrollee. Learn how the salesforce flow updates an electronic verification request status to time out. Understand the prerequisites before making any customizations to this flow. - Einstein Generative AI for Pharmacy Benefits Verification
Harness the power of Einstein generative AI to streamline patient services rep's daily tasks. Pharmacy Benefits Verification uses Einstein generative AI-based flows to generate a call script and a benefits summary. - Use Pharmacy Benefits Verification
Pharmacy Benefits Verification improves patient access and adherence to care by helping representatives to start the patient’s medication early. Help caregivers and patients reduce the time and effort required to determine the covered pharmacy benefits. Patient services representatives can assist patients by getting a clear picture of their pharmacy benefits coverage such as co-pay, co-insurance, and other coverage details. They can also generate a concise summary of patient’s pharmacy benefit details using Einstein’s Generative AI auto-launched flows.
