What an eligibility check can (and can't) tell you about pharmacy benefits

Most people's health insurance coverage is really two separate benefit systems: medical benefits and pharmacy benefits.

Medical benefits cover provider visits, procedures, and treatments – the things a provider typically bills for.

Pharmacy benefits cover prescription drugs. Most medical payers route pharmacy benefits through a separate entity, called a pharmacy benefit manager (PBM). Major PBMs include CVS Caremark, Express Scripts, and Optum Rx.

An eligibility check – like those provided by Stedi's Eligibility APIs – can confirm that a patient has pharmacy coverage. Eligibility checks often also tell you the PBM for the patient's health plan.

What eligibility checks can't tell you is what a specific drug costs. Drug-level benefits live with the patient's PBM and require different transactions that run on different rails.

What pharmacy information comes back in an eligibility response?

When you run an eligibility check for medical services, you typically provide a Service Type Code (STC). The code tells the payer what type of benefits you'd like returned in the response.

STC 30 (Health Benefit Plan Coverage) is the baseline or default STC for medical eligibility checks. If you run a check with STC 30, medical payers must return benefits for a core set of service types the plan covers. That core set includes benefits for STC 88 (Pharmacy).

Pharmacy coverage

Most payers only indicate whether a patient has coverage for pharmacy benefits (STC 88). They often don't include specific benefit details.

For example, a pharmacy-related benefitsInformation object from a Stedi JSON Eligibility API response:

{
  "code": "1",                // Active coverage
  "serviceTypeCodes": ["88"], // Pharmacy
  ...
}

{
  "code": "1",                // Active coverage
  "serviceTypeCodes": ["88"], // Pharmacy
  ...
}

{
  "code": "1",                // Active coverage
  "serviceTypeCodes": ["88"], // Pharmacy
  ...
}

{
  "code": "1",                // Active coverage
  "serviceTypeCodes": ["88"], // Pharmacy
  ...
}

{
  "code": "1",                // Active coverage
  "serviceTypeCodes": ["88"], // Pharmacy
  ...
}

Cost sharing for pharmacy benefits

In rare cases, payers return more specific pharmacy benefit details, such as co-payments and out-of-pocket maximums.

The following example shows a patient's out of pocket (stop loss) benefit per calendar year for pharmacy services:

{
  "code": "G",                // Out of Pocket (Stop Loss)
  "serviceTypeCodes": ["88"], // Pharmacy
  "benefitAmount": "6000",    // Patient pays $6,000 out of pocket maximum
  "timeQualifierCode": "23",  // For the calendar year
  "coverageLevelCode": "FAM", // Applies to family benefits
  "inPlanNetworkIndicatorCode": "Y", // For in-network providers
  "additionalInformation": [
    {
      "description": "Copay does apply to member's out-of-pocket maximum"
    }
  ]
}

{
  "code": "G",                // Out of Pocket (Stop Loss)
  "serviceTypeCodes": ["88"], // Pharmacy
  "benefitAmount": "6000",    // Patient pays $6,000 out of pocket maximum
  "timeQualifierCode": "23",  // For the calendar year
  "coverageLevelCode": "FAM", // Applies to family benefits
  "inPlanNetworkIndicatorCode": "Y", // For in-network providers
  "additionalInformation": [
    {
      "description": "Copay does apply to member's out-of-pocket maximum"
    }
  ]
}

{
  "code": "G",                // Out of Pocket (Stop Loss)
  "serviceTypeCodes": ["88"], // Pharmacy
  "benefitAmount": "6000",    // Patient pays $6,000 out of pocket maximum
  "timeQualifierCode": "23",  // For the calendar year
  "coverageLevelCode": "FAM", // Applies to family benefits
  "inPlanNetworkIndicatorCode": "Y", // For in-network providers
  "additionalInformation": [
    {
      "description": "Copay does apply to member's out-of-pocket maximum"
    }
  ]
}

{
  "code": "G",                // Out of Pocket (Stop Loss)
  "serviceTypeCodes": ["88"], // Pharmacy
  "benefitAmount": "6000",    // Patient pays $6,000 out of pocket maximum
  "timeQualifierCode": "23",  // For the calendar year
  "coverageLevelCode": "FAM", // Applies to family benefits
  "inPlanNetworkIndicatorCode": "Y", // For in-network providers
  "additionalInformation": [
    {
      "description": "Copay does apply to member's out-of-pocket maximum"
    }
  ]
}

{
  "code": "G",                // Out of Pocket (Stop Loss)
  "serviceTypeCodes": ["88"], // Pharmacy
  "benefitAmount": "6000",    // Patient pays $6,000 out of pocket maximum
  "timeQualifierCode": "23",  // For the calendar year
  "coverageLevelCode": "FAM", // Applies to family benefits
  "inPlanNetworkIndicatorCode": "Y", // For in-network providers
  "additionalInformation": [
    {
      "description": "Copay does apply to member's out-of-pocket maximum"
    }
  ]
}

These are plan-level cost-sharing amounts, not what a specific prescription will cost.

Pharmacy benefit manager (PBM) information

Payers often (but not always) return the PBM's information, such as name and phone number, in the eligibility response.

For example, a pharmacy-related benefitsRelatedEntities object from a Stedi JSON Eligibility API response:

{
  "code": "U",                // Contact related entity
  "serviceTypeCodes": ["88"], // for Pharmacy benefits
  "benefitsRelatedEntities": [
    {
      "entityIdentifier": "Third-Party Administrator",
      "entityType": "Non-Person Entity",
      "entityName": "Acme Pharmacy Services",
      "contactInformation": {
        "contacts": [
          {
            "communicationMode": "Telephone",
            "communicationNumber": "1234567890"
          }
        ]
      }
    }
  ]
}

{
  "code": "U",                // Contact related entity
  "serviceTypeCodes": ["88"], // for Pharmacy benefits
  "benefitsRelatedEntities": [
    {
      "entityIdentifier": "Third-Party Administrator",
      "entityType": "Non-Person Entity",
      "entityName": "Acme Pharmacy Services",
      "contactInformation": {
        "contacts": [
          {
            "communicationMode": "Telephone",
            "communicationNumber": "1234567890"
          }
        ]
      }
    }
  ]
}

{
  "code": "U",                // Contact related entity
  "serviceTypeCodes": ["88"], // for Pharmacy benefits
  "benefitsRelatedEntities": [
    {
      "entityIdentifier": "Third-Party Administrator",
      "entityType": "Non-Person Entity",
      "entityName": "Acme Pharmacy Services",
      "contactInformation": {
        "contacts": [
          {
            "communicationMode": "Telephone",
            "communicationNumber": "1234567890"
          }
        ]
      }
    }
  ]
}

{
  "code": "U",                // Contact related entity
  "serviceTypeCodes": ["88"], // for Pharmacy benefits
  "benefitsRelatedEntities": [
    {
      "entityIdentifier": "Third-Party Administrator",
      "entityType": "Non-Person Entity",
      "entityName": "Acme Pharmacy Services",
      "contactInformation": {
        "contacts": [
          {
            "communicationMode": "Telephone",
            "communicationNumber": "1234567890"
          }
        ]
      }
    }
  ]
}

{
  "code": "U",                // Contact related entity
  "serviceTypeCodes": ["88"], // for Pharmacy benefits
  "benefitsRelatedEntities": [
    {
      "entityIdentifier": "Third-Party Administrator",
      "entityType": "Non-Person Entity",
      "entityName": "Acme Pharmacy Services",
      "contactInformation": {
        "contacts": [
          {
            "communicationMode": "Telephone",
            "communicationNumber": "1234567890"
          }
        ]
      }
    }
  ]
}

Tip: Don’t rely on the entityIdentifier field to identify PBMs. The value can vary between payers.

Pharmacy-related STCs

When payers return pharmacy benefits, it's usually for STC 30 and 88.

The table below lists other pharmacy-related STCs. You can test payer support for these STCs, but they rarely unlock more data. Payers typically respond with the same active or inactive answer they'd return for STC 30 or 88.

There's no STC for specialty pharmacy – the full STC list doesn't include one.

What an eligibility check won't tell you

Generally, eligibility checks won't give you information about specific drugs or prescriptions, including:

• Whether a specific drug is covered by a patient's insurance

• The patient's out-of-pocket cost for the drug

• Prior authorization or step therapy requirements

• Quantity limits or days' supply rules

• Whether the prescription must be filled at retail, mail order, or a specialty pharmacy

Checking prescription benefits

To get coverage or cost information for a specific drug, you typically need to run a prescription benefit transaction that’s separate from an eligibility check. These transactions return drug-level details in real time, and they happen at two points in the prescription workflow:

• Prescribers, typically providers, run a check at the point of prescribing to see what a drug will cost a patient before sending the prescription. These transactions use the NCPDP Real-Time Prescription Benefit (RTPB) Standard.

• Pharmacies submit a claim to the PBM for real-time adjudication when filling a prescription. These transactions use the NCPDP Telecommunication Standard for real-time claim adjudication.

Both return drug-level cost and coverage from the patient's PBM, and both run on different rails than an eligibility check.

Differences between prescription benefit transactions and eligibility checks

Aside from the drug-level details they return, the biggest difference between prescription benefit transactions and eligibility checks is that they run on different infrastructure.

Per HIPAA, eligibility checks must be exchanged using X12 EDI: a 270 eligibility request and a 271 eligibility response.

Prescription benefit transactions instead use standards from the National Council for Prescription Drug Programs (NCPDP), the pharmacy industry's standards body.

The following table outlines the major differences between prescription benefit transactions and eligibility checks.

Does Stedi support prescription benefit transactions?

No. As a healthcare clearinghouse, Stedi exchanges data with the medical, dental, and vision payers in the Stedi Payer Network using X12 EDI. We don't support prescription benefit transactions or connect to PBMs.

What are RxBINs, RxPCNs, and RxGroups?

Pharmacy Bank Identification Numbers (RxBINs), Processor Control Numbers (RxPCNs), and RxGroups tell pharmacies where to send claims. These IDs are often on members' insurance cards.

Do eligibility checks return RxBINs, RxPCNs, or RxGroups?

No. Payers don't typically include RxBINs, RxPCNs, or RxGroups in their eligibility responses. You can typically get them from the patient's insurance ID card instead.

The exception: specialty drugs

Specialty drugs can fall under either medical benefits or pharmacy benefits. How the drug is administered usually determines which one.

Provider-administered drugs

Provider-administered drugs, like infusions and injections, are often covered under a patient's medical benefit. The provider buys the drug, administers it, and bills the payer on a medical claim using HCPCS J-codes. For these drugs, standard medical workflows apply: eligibility checks and claims through a clearinghouse.

Self-administered drugs

Self-administered specialty drugs, where the patient picks up the drug at a pharmacy or receives it by mail, usually fall under pharmacy benefits. For these drugs, coverage and cost details typically live with the PBM, not the medical payer.

Run eligibility checks with Stedi

You can try out Stedi's eligibility checks for free with a sandbox account. The sandbox gives you access to mock eligibility requests for building test integrations.

You can upgrade to production whenever you're ready. There are no monthly minimums or setup fees. You only pay for the transactions you use.

To get started, sign up for free. It takes less than two minutes. No credit card is required.