BLOG: Medical vs. Pharmacy Benefit: A Look at UM Differences
| Medical | Pharmacy | |
| Definition | MD or DME administered | Drugs except certain vaccines |
| Definition | Devices | Drugs |
| Medicare Benefit | Part B | Part D |
| Code | HCPCS | NDC |
Are benefits better on Medicare or Medicaid?
Much better on Medicaid, if you qualify for it Medicaid pays for everything. Medicare has a monthly premium for most, with Medicare you pay co pays and deductibles. The problem with both programs is that their benefits exist only in theory.
Who are eligible for medical benefits?
You:
- Receive financial compensation (payments) from VA for a service-connected disability
- Were discharged for a disability resulting from something that happened to you in the line of duty
- Were discharged for a disability that got worse in the line of duty
- Are a recently discharged combat Veteran
- Get a VA pension
- Are a former prisoner of war (POW)
Can you have both Medicare and VA benefits?
The answer is that you could probably benefit from having both VA benefits and Medicare. The VA encourages you to consider enrolling in Medicare as soon as you’re eligible because Medicare and VA benefits don’t work together – and you may have to pay a penalty if you end up enrolling in Medicare later.
What are the benefits of Pharmacy?
List of the Pros of Becoming a Pharmacist
- You’re going to be compensated well in this career. Once you have graduated with your PharmD degree, there is an excellent chance that you’ll be earning six figures in ...
- There are a wide variety of job opportunities available to pharmacists. ...
- You’re not required to hold a license for all pharmacy positions. ...
How much of specialty drug spending is medical?
With approximately 50% of the specialty drug spend occurring in the medical benefit and a variety of payment and dispensing options, it can be difficult for employers to get full transparency on specialty drug spending or overall utilization.
What is the strategy of a single benefits manager?
Strategy #1: Specialty drugs under one benefit. Regardless of which benefit covers the drug, a single benefits manager is responsible for evaluating the appropriateness of a therapy and its cost or value which addresses the need to obtain a more accurate picture of overall costs. Disadvantages/Limitations:
What are specialty drugs?
Specialty drugs play an increasingly important role in the treatment of chronic conditions such as multiple sclerosis, rheumatoid arthritis, psoriasis, inflammatory bowel disease and cancer, yet little is known regarding the comprehensive medical and pharmacy benefit utilization and cost trends for these conditions .
What is a condition that requires multiple drug benefits?
An example of a condition requiring service under multiple drug benefits is common variable immune deficiency (CVID). CVID is a genetic immune disorder that causes a profound reduction in the production of protective antibodies. CVID patients are treated with lifelong immunoglobulin replacement therapy.
What is specialty pharmacy?
The true definition of a specialty pharmacy medication is an area of continuing debate. Using URAC’s definition, specialty drugs or pharmaceuticals usually require specialty handling, administration, unique inventory management, a high level of patient monitoring, and more intense support than conventional therapies.
What is specialty medication management?
Managing specialty medications is a complex process for health plans that requires coordination between the pharmacy director and medical director to ensure the optimal management of these expensive medications as well as of health plan resources.
Can a pharmacy split billing?
Split billing is not an ideal solution, since it requires the pharmacy provider to generate 2 claims for each date of service. As a result, the health plan must match the pharmacy and medical claims at some point during the payment or audit process.
How are Medicare and pharmacy different?
Medicare medical and pharmacy benefits are very different in their utilization management (UM). As such, it is valuable to know the distinctions between benefits, as strategies differ depending on which ones apply. The most significant differentiator is the fact that utilization is typically greater under the medical benefit, ...
Why would an ACO favor use of the pharmacy benefit?
As a result, in therapeutic areas that have treatments in both pharmacy and medical benefits, an ACO would favor use of the pharmacy benefit, as it looks to lower its total cost of care through reducing use of medical benefits.
What would happen if digital therapeutics existed under the pharmacy benefit?
For CMS, if digital therapeutics existed under the pharmacy benefit, the responsibility for utilization management and costs would fall on the prescription drug plans. For manufacturers, utilization management would be greater under the Medicare medical benefit, as CMS currently does not perform any prospective authorization.
Does Medicare Part D pharmacy benefit include ACOs?
These incentives are counter-balanced by the motivations of ACOs. Even though ACOs are responsible for total cost of care by law, this does not include the Medicare Part D pharmacy benefit but does include the medical benefit.
Is utilization management more restrictive under the pharmacy benefit than the medical benefit?
As a result, utilization management is significantly more restrictive under the pharmacy benefit over the medical benefit. Utilization differences also exist with prescribers and Accountable Care Organizations (ACOs).
What is Medicare Part B?
HCP-administered specialty drugs/biologics 2. Medicare Part B (fee-for-service) 80 % of patients with Medicare Part B also have supplemental insurance3. Medigap is insurance by a private health plan that provides additional payments after Medicare has issued payment 3.
What is specialty medicine?
Specialty drugs/biologics are used to treat complex and/or chronic conditions and may require special handling and administration. Depending on the mode of administration, specialty drugs/biologics may be covered by a health plan as a medical benefit, pharmacy benefit, or both.
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