One of the most common barriers to medication adherence is cost. As patient out-of-pocket expenses increase, medication adherence tends to decrease, leading to poorer health outcomes and potentially higher healthcare costs over time. Despite the importance of affordability, prescribers have historically had limited access to patient-specific drug cost information while making prescribing decisions.

Real-Time Prescription Benefit (RTPB) technology was developed to address this challenge by providing patient-specific coverage and cost information during the prescribing process. As adoption continues to grow and regulatory requirements evolve, RTPB is becoming an increasingly important tool for improving medication access and reducing administrative burden across the healthcare system.

What Is RTPB?

RTPB is a real-time electronic transaction that allows prescribers and pharmacists to obtain patient-specific prescription benefit information from a pharmacy benefit manager (PBM). The transaction returns information such as expected patient out-of-pocket costs, formulary status, coverage restrictions, prior authorization requirements, and available therapeutic alternatives.

Unlike traditional formulary references, RTPB provides information tailored to an individual patient’s insurance benefits and medication history. This allows clinicians to evaluate affordability and coverage before a prescription is dispensed and, in many cases, before it is even sent to the pharmacy.

Who Benefits from RTPB?

Patients are the primary beneficiaries of RTPB. By identifying lower-cost medications, preferred formulary products, and alternatives that avoid coverage restrictions, RTPB can help reduce out-of-pocket expenses and improve prescription fill rates.

Prescribers benefit by gaining visibility into medication costs during the patient visit. Instead of learning about coverage problems after a prescription reaches the pharmacy, providers can proactively select affordable and covered therapies while discussing treatment options with patients.

RTPB also helps reduce administrative burden. When prior authorization requirements are identified before a prescription is submitted, providers may choose covered alternatives that eliminate the need for additional paperwork and treatment delays.

Pharmacists play an important role as well. While RTPB data originates during prescribing, pharmacists often serve as the bridge between benefit information and patient care. Pharmacists help patients understand their coverage options, identify affordable alternatives, and resolve access barriers when coverage issues arise.

Rapid Adoption Across Healthcare

Adoption of RTPB has accelerated significantly in recent years. More than 900,000 prescribers used RTPB over one billion times in 2025 to access patient-specific cost and coverage information. This growth reflects increasing demand for point-of-prescribing cost transparency and broader integration of RTPB functionality within electronic health record (EHR) and electronic prescribing systems.

Several use cases have emerged as particularly valuable:

• Point-of-prescribing cost transparency allows providers to view patient-specific drug costs, formulary status, and prior authorization requirements before sending a prescription.
• Alternative therapy selection helps identify lower-cost or preferred formulary medications when a prescribed product is expensive or not covered.
• Prior authorization avoidance reduces delays in care by identifying covered alternatives that may not require additional approval.
• Refill and maintenance therapy optimization can identify lower-cost pharmacies, mail-order opportunities, or alternative days’ supply options that support long-term medication adherence.

The Current State of RTPB Standards

Federal policy has played a major role in RTPB adoption. Beginning January 1, 2021, Medicare Part D sponsors were required by the Centers for Medicare & Medicaid Services (CMS) to support at least one Real-Time Benefit Tool (RTBT) integrated with an electronic prescribing system or EHR. However, CMS did not initially require a specific transaction standard for how those benefit requests and responses were exchanged.

As RTPB adoption expanded, industry stakeholders increasingly aligned around the National Council for Prescription Drug Programs (NCPDP) RTPB Standard. The standard provides a consistent framework for exchanging benefit information among prescribers, PBMs, pharmacies, and health information technology vendors.

The next major milestone arrives on January 1, 2027, when CMS will require Medicare Part D sponsors supporting prescriber RTBTs to use NCPDP RTPB Standard Version 13. This requirement is expected to improve interoperability and promote greater consistency across healthcare systems.

Outstanding Gaps and Opportunities

Despite substantial progress, important opportunities remain to improve RTPB performance and reliability.

One ongoing challenge is response quality. For RTPB to support effective prescribing decisions, PBMs must consistently return therapeutically appropriate alternatives that are truly covered under a patient’s benefit plan. Inaccurate or incomplete alternative recommendations can limit the usefulness of the transaction.

Coverage designation errors also remain a concern. In some cases, covered alternatives may be incorrectly flagged as “Not Covered,” creating confusion for providers and potentially leading to unnecessary medication changes or administrative work.

Member matching failures continue to present challenges as well. When patient eligibility information cannot be accurately matched between systems, RTPB transactions may fail or return incomplete results. Addressing these issues requires coordination among PBMs, pharmacies, EHR vendors, and other technology stakeholders.

Looking Ahead

RTPB represents an important step toward greater transparency in prescription drug benefits. By providing patient-specific cost and coverage information at the point of prescribing, RTPB helps providers make informed treatment decisions, supports medication affordability, and reduces administrative burden.

Adoption continues to grow, and upcoming CMS requirements are expected to further standardize RTPB transactions across the healthcare ecosystem. However, continued improvement in response quality, alternative therapy recommendations, and member matching will be necessary to fully realize RTPB’s potential.

As healthcare continues to focus on affordability and access, RTPB is increasingly becoming a foundational tool that helps connect clinical decision-making with real-world medication costs, ultimately improving the likelihood that patients can obtain and remain on the therapies they need.