Pharmacy costs get all the press for rising prices; however, brokers and plan sponsors need to consider medical pharmacy if they want a complete picture of plan spend.

Medical pharmacy is the management of drugs billed under the medical benefit. Most often, these drugs are injectable and infusion medicines. These drugs are administered by a healthcare provider in an in-patient setting, outpatient clinic, or infusion center. Because these drugs typically require additional supplies or services, coverage on the medical plan allows the medications, supplies, and services to be billed together.

Commonly, specialty medications are billed under the medical benefit. Unlike drugs billed under the pharmacy benefit, medical pharmacy is not subject to rebates, and the reimbursement process is more complex and drawn out.

The level of claim detail available for medical pharmacy is also less transparent than pharmacy claims. With pharmacy claims, stakeholders can see when and where a script is filled, plan and co-pay information, and drug classification and therapeutic details. While these details may be available in medical pharmacy claims, a difference in formatting, including J Codes, can cloud the visibility of pharmacy information.

Bridging the gap between pharmacy and medical pharmacy allows stakeholders to see all pharmacy-related plan costs to improve formulary management, clinical care, and cost containment.

Read this blog post for a more detailed look at medical pharmacy, specifically as applied to specialty drugs.

Crafting a benefits strategy with cost and clinical transparency for both medical and pharmacy channels is complex. That is why Prescription Care Management (PCM) has done the work for you. In addition to a comprehensive pharmacy platform, PCM offers a medical platform that provides visibility into specialty medications covered by the medical channel. Click here, to see how PCM is helping payors get a holistic plan view.

Published: June 28, 2022