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

To ease 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.

Additional Resources

Evaluation of Medical Specialty Medications: Utilization and Management OpportunitiesMilliman, 2014

Health Policy Brief: Specialty PharmaceuticalsHealth Affairs, November 2013