What to expect
An estimate is not always possible, and the screen will tell you why.
Coverage and pricing come from the patient's plan. Sometimes we cannot ask, and sometimes we ask and the plan does not answer. Either way you get a short explanation rather than an empty screen, and in several cases there is something you can do about it.
Reasons we do not ask the plan
A benefit check needs a patient, a prescriber, a medication, a pharmacy, and current pharmacy coverage. If one of those is missing, there is no question to ask, so no request goes out.
No pharmacy on the prescription
Price depends on where the prescription is filled, so we cannot price one without a pharmacy.
What to do: select a pharmacy on the prescription and run the check again.
No recent eligibility on file
The benefit check is priced against the patient's pharmacy coverage, which we get from an eligibility response. If one has never been received, or the most recent one is more than three days old, we do not have current coverage to price against.
What to do: run eligibility for the patient, then run the check again. This is pharmacy coverage specifically, which is not the same as the insurance on the patient's chart for billing.
The medication is not a coded product
Compounds and free text prescriptions do not carry a drug code, and a plan can only price a specific product. The same applies to a medication in our system that has no code attached to it.
What to do: nothing. Prescribe as you normally would.
Benefit checks are turned off for you
Benefit checks are controlled at both the practice and the user level, so an individual can have them off while the rest of the practice has them on.
What to do: ask your system administrator if you expected to see them.
Reasons the plan does not give a price
These appear after the request has gone out. The plan replied, but not with the answer you wanted.
The plan does not recognize the pharmacy
The pharmacy is not in the plan's network, or the plan does not price that kind of pharmacy. Mail order and specialty pharmacies are common cases.
What to do: if the screen offers the same medication at other pharmacies, one of those will be priced. See Switching to a Different Drug or Pharmacy.
The plan answered but gave no amount
Some plans return coverage without a dollar figure. You may still learn whether the medication is covered, whether it needs a prior authorization, and whether alternatives exist, even with no price attached.
What to do: use what the plan did return. A coverage answer on its own is still useful.
The plan did not respond in time
We wait a short time for an answer so that prescribing is not held up. If the plan is slow or unavailable, the screen says so.
What to do: try once more if you want. Otherwise send the prescription.
Formulary status not determined
This one comes from a different source. The Coverage panel on the prescription pad uses formulary lists the plan publishes in advance, which is how it can show a tier the moment you pick a drug, without contacting anyone. When a medication does not appear on the list we were given, its status is not determined.
It does not mean the medication is not covered. It means the published list does not say. The benefit check, which asks the plan directly, is the better answer when you need one, and it is often available even when the formulary list is silent.
None of this stops you prescribing. Coverage and pricing are there to inform the decision, not to gate it. If the information is not available, prescribe as you would have before.
