Small steps drive big outcomes - How eligibility and F&B data can be managed to improve patient safety, lower costs and ensure quality care

Sep 17, 2026

Small Steps Drive Big Outcomes examines how eligibility and formulary & benefit (F&B) data should be managed to strengthen patient safety, reduce costs, and maintain quality care. The paper explains how F&B information and structured files underpin ePrescribing capabilities such as Real-Time Benefit Check (RTBC), electronic prior authorization (ePA), and specialty enrollment. It also addresses data accuracy, timeliness, and completeness, showing how reliable eligibility records improve downstream transaction performance and accelerate access to appropriate therapies.

LanguageEnglish

CategoryGeneral

FormatPDF

Pages8

Reading Time3 min

AccessFree to download

Introduction

Eligibility and F&B as the foundation for ePrescribing

RTBC, ePA, and specialty enrollment relationships

Data completeness impacts on trust and downstream transactions

Payer/PBM objectives and standardized implementation

Small steps drive big outcomes: How eligibility and formulary and benefit data can be managed to improve patient safety, lower costs and ensure quality care PRESENTED BY: PUBLISHED BY: © 2021 Questex Content Marketing. All rights reserved. All registered trademarks are property of their respective owners. Introduction It is a well-known paradigm that small and incremental changes can lead to large outcomes, and when it comes to how eligibility and formulary and benefit (F&B) data is managed, this old adage holds alot of weight. Traditionally, formulary information available in electronic health records (EHRs)—such as coverage, formulary status, restrictions, and co-payment amounts—have been plagued with inaccuracies, inconsistencies and timeliness. This has resulted in a lack of trust in the data.1 Over the years, a focus on improving the reliability of this data has taken place in small steps, giving way to improved patient safety and lower cost while ensuring quality care. In this white paper, we will discuss the benefit of F&B and eligibility data on downstream processes and how data quality improvement efforts is benefiting providers and patients alike. ePrescribing transactions: Why eligibility is the foundation for downstream processes flow Eligibility is crucial to the management of F&B information and forms the foundation for ePrescribing transactions such as realtime benefit check (RTBC), electronic prior authorization (ePA), and specialty enrollment. F&B and RTBC are two distinct processes that take place at different times during the ePrescribing process. F&B data is formatted in a systematized flat file and provides information to the provider about what is covered and what is not covered under a patient’s pharmacy benefit plan.1 These F&B records can contain any medication or benefit restrictions, prior authorization, or step-therapy requirements and dosage limits, as well as alternatives for the medication. The formulary file is focused at the plan level to offer the providers insights before choosing a medication. F&B provides several therapeutic alternatives for every medication, along with formulary coverage information. The provider, with group/ plan level information provided by F&B early on in the workflow before selecting the medication, dosage or filling pharmacy for an individual patient, can hone in on a smaller subset of medications that will be covered by the patient’s prescription drug plan and potentially which medications will be covered without a prior authorization. It is very important for providers to be able to access Eligibility is crucial to the management of formulary and benefit (F&B) information and forms the foundation for ePrescribing transactions such as Real-Time Benefit Check (RTBC), electronic prior authorization (ePA), and specialty enrollment. 2 MAY 2021 SMALL STEPS DRIVE BIG OUTCOMES: HOW ELIGIBILITY AND F&B DATA CAN BE MANAGED TO IMPROVE PATIENT SAFETY, LOWER COSTS AND ENSURE QUALITY CARE this information within their EHRs, as the methods that prescription drug plans use to share their formularies outside of the EHR are less effective because they are outside the prescribing workflow. A recently published Surescripts data brief.2 illustrates why providers greatly value these benefit insights. Indeed, nearly all survey respondents said they value access to group/plan level prescription benefit information within the e-prescribing workflow. After the provider selects a medication and fully specifies the prescription, the RTBC is complete. This novel technology, presented in the EHR, informs providers about restrictions and out-of-pocket costs.3 In comparison to the F&B transaction, the RTBC has detailed patient-level information concerning coverage, cost and alternatives, calculated knowing the patients deductible status. Providers gain areal-time view of patient-specific cost at the pharmacy and coverage based on where the patient is in their

FAQs

What problem does the paper identify with traditional formulary and benefit data in EHRs?

It identifies inaccuracies, inconsistencies, and poor timeliness that reduce trust in the data. These issues can weaken decision-making during prescribing workflows.

How does eligibility data support downstream ePrescribing processes?

Eligibility is presented as the foundation for transactions such as RTBC, electronic prior authorization (ePA), and specialty enrollment. Without reliable eligibility records, later steps like RTBC may not run correctly.

What is the role of RTBC compared with the F&B transaction?

RTBC provides patient-level information about coverage, cost, and alternatives, accounting for the patient’s deductible status. In contrast, F&B focuses on plan-level coverage insights earlier in the workflow.

Sep 17, 2026

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