Specialty Drugs. A Medical or a Pharmacy Benefit?

In recent years, in an effort to better manage utilization, the existing system for benefits billing has undergone a major shift. Payers have traditionally managed oral medications under the pharmacy benefit and medications that are infused or injected as part of the medical benefit. Health plans and other payers have been reimbursing providers under the medical benefit for injection and infusion services for some time, and injected or infused drugs have naturally been billed as part of the same claim. Self-injected and newer oral specialty medications have been the outlier, landing on both sides of the benefit divide.

How the Innovations Change the Landscape

Innovative specialty products largely administered via injection or infusion have revolutionized treatment options in areas such as hematology, oncology and rheumatology. These biologic products are generally priced significantly higher than traditional oral medications and are increasingly accounting for a larger share of total drug spending.

This means:

  • For the specialists who regularly prescribe and administer these specialty drugs, buy and bill has added an incremental revenue stream to their practices.
  • For health plan executives and pharmacy benefit managers eager to contain drug costs, the value of covering these specialty drugs in now on their radar.

So, do you have a side?

PHC_Perspective_SpecPharmShould coverage of new biologic injectable products remain under the medical benefit, or shift to the pharmacy benefit? Health plans are exploring utilization management options and proceeding cautiously, considering the many implications such a shift could have. And the coming months will certainly see the debate intensify. This issue will remain a hot topic, and at Pinnacle, we will be closely monitoring the impact of this emerging trend on the healthcare industry. What are your thoughts?

Pinnacle Can Help You Rise Above the Trends

Comprised of experts from diverse healthcare industry backgrounds, the Pinnacle team anticipates and helps you innovate to rise above, no matter the trend. Our key insights and unparalleled understanding of the issues you face allows for the creation of clear and compelling solutions for you and your clients. If you would like to hear more about how Pinnacle can help you, please contact us.

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