Managing the Intersection of Medical and Pharmacy Benefits

BACKGROUND: Because of the unique features of specialty pharmaceuticals and insurance plans, specialty pharmaceutical products can be paid through the pharmacy benefit or the medical benefit. While most pharmacists are very comfortable with the conventions of reimbursement in the pharmacy benefit, they are less familiar with the processes for payment in the medical benefit. OBJECTIVES: To review the 2 parallel processes for payment of specialty pharmaceuticals, the pharmacy benefit and the medical benefit, and tocompare and contrast these 2 processes. SUMMARY: The medical benefit and pharmacy benefit processes for payment of specialty pharmaceuticals use different claim forms, product codings ystems, pricing conventions, and contracts. Even though the services delivered can be identical, the financial aspects of paying for these services are quite different. CONCLUSIONS: Pharmacists who are interested in entering the specialtypharmacy arena, either as a provider or manager of providers, need to understand the payment processes for specialty pharmaceuticals through both the pharmacy and medical benefits.