Comparing Medical and Pharmacy Benefit Reimbursement

Helping a provider determine the most sustainable insurance pathway for specialty medications.

The Challenge

Some specialty medications can be billed through either the patient’s medical benefit or pharmacy benefit. Each pathway may have different:

• Reimbursement rates.
• Prior authorization requirements.
• Claims procedures.
• Vendors.
• Insurance rules.
• Administrative responsibilities.

A provider may lose money under one benefit while receiving more appropriate reimbursement under the other.

The Consulting Approach

The Pharmacists Care Team recommended evaluating both pathways before deciding how a medication should be processed.

The strategy included:

• Checking reimbursement through the medical benefit.
• Checking reimbursement through the pharmacy benefit.
• Comparing medication costs with projected payments.
• Reviewing prior authorization requirements for both options.
• Identifying the administrative workload involved.
• Training staff to evaluate each patient’s coverage.
• Developing a process for selecting the most appropriate pathway.

The Potential Impact

This approach can help providers:

• Reduce losses on specialty medications.
• Improve reimbursement.
• Make better use of both insurance benefits.
• Create more consistent internal procedures.
• Prepare staff for complicated authorization requirements.
• Continue offering important treatments to patients.

Services Featured

Benefit Strategy · Prior Authorization Workflow · Reimbursement Optimization · Staff Training