Medical Benefit Drug Management

Prescription drugs are covered either through a health plan’s pharmacy or medical benefit. This designation largely depends on whether the drug is self-administered or given in a clinical setting. While the reimbursement process through the pharmacy benefit is straightforward and well-managed by PBMs, reimbursement through the medical benefit is much more imprecise. Due to variability in medical claims submission processes and other reimbursement practices, it is difficult for payers to accurately evaluate medication costs and patient utilization in the medical benefit.

To ease this confusion, payers and PBMs are exploring ways to apply the tools successfully used in the pharmacy benefit to the medical benefit. Streamlining coverage would allow for the implementation of treatment pathways and more comprehensive utilization management interventions for targeted conditions. In the long-term, this will exert downward pressure on drug prices and will provide more robust information on specialty drug usage and outcomes.