Medical Benefit Drug Management

Return to Policy & Issues

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.


Press Releases

Additional Resources

2015 Trend Report

Magellan Rx — Magellan Rx Management is pleased to present the sixth edition of our Medical Pharmacy Trend Report,™ the...

Keep Reading

Related Card Stacks

What services do specialty pharmacies provide?

Specialty pharmacy services are designed for a small, but growing population of patients with relatively complex and chronic diseases that require expensive and challenging drug regimens.

Learn More

What tools do PBMs use?

The total costs and utilization of specialty drugs will have a substantial impact on overall health care costs during the next decade.

Learn More

Physician Perspectives on Specialty Medications (North Star Opinion Research)

There are high levels of usage and satisfaction among physicians with specialty pharmacies.

Learn More