The Critical Role of Medication Guidance in Benefit Navigation 

By: Emily Crisano and Jason Peterson, Clinical Pharmacists at Emry Health

Navigating the maze of prescription drug access is fraught with obstacles—from understanding insurance rules to coordinating multiple medications and dealing with various prescribers. For many patients, even acquiring a single prescribed medication can be a daunting challenge, compounded by high costs and strict insurance regulations. 

The Complexity of Prescription Approval 

Consider a typical scenario: A physician’s first-choice drug may not be covered by a patient’s insurance without prior authorization if it’s not the preferred option under their plan. When the patient attempts to pick up the medication, they may face the need for prior authorization. However, there are often similar, equally effective medications available that do not require prior authorization and are preferred by the insurance provider. A clinically trained patient advocate can assist in navigating these situations, minimizing time, resources, and frustrations. 

The Role of Pharmacy Support in Benefit Navigation 

This is where the expertise of clinical pharmacists becomes invaluable. Pharmacy benefit navigators serve as liaisons, ensuring effective communication between patients, health plans and providers and facilitating quicker resolution of issues like prior authorizations. They are equipped with the knowledge to suggest the most cost effective, appropriate medications that meet the insurance criteria, reducing the time patients spend waiting for therapy. 

Moreover, pharmacists can help manage the complexity of multiple medications across different providers, ensuring that patients receive comprehensive care. This is particularly crucial for patients managing chronic conditions, who may be juggling several prescriptions that need to be carefully coordinated to avoid adverse interactions and ensure optimal efficacy. 

Addressing Financial Barriers 

Another significant aspect of pharmacy support is assistance with navigating financial barriers to medication access. Even when a medication is approved, sometimes the cost can be prohibitive. Pharmacists can guide patients through the maze of manufacturer discount programs and coupon cards, which are often underutilized due to lack of awareness or complexity in applying for them. 

For example, a patient may qualify for a manufacturer’s discount that significantly reduces the cost of medication, but without the help of a knowledgeable pharmacist, they might never discover this option. 

The Impact of Effective Medication Guidance 

Effective medication guidance can drastically reduce the number of patients who abandon their prescriptions due to the convoluted process and high costs. By ensuring that patients have access to necessary medications without unnecessary delays or financial burdens, pharmacists can decrease the likelihood of hospitalizations and other costly medical interventions down the line. This proactive approach not only saves costs for both patients and healthcare plans but also significantly improves health outcomes. 

As new—more expensive drugs—continue to hit the market, the role of pharmacists in benefit navigation becomes increasingly critical. Their expertise not only helps in simplifying the medication acquisition process but also ensures that patients receive the medications they need quickly and at the most affordable cost. For those managing multiple medications or those with complex health needs, this support is not just beneficial—it’s essential. 


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