Medical Benefit
The medical benefit covers a broad range of services—e.g., in-patient, X-rays, diagnostics, office visits—for common chronic and acute conditions. Many states and other insurers may not realize, however, that some medical pharmacy services and procedures are covered under the medical benefit, and many of these claims are classified as Specialty Pharmacy. For example, products such as Herceptin or Rituxan for cancer, and Flolan or Remodulin for pulmonary hypertension, are typically administered in the physician’s office, an infusion suite, or in the patient’s home and are often covered under a traditional medical plan benefit. The cost of drugs and services that qualify under the medical benefit are expected to outpace drugs paid under the traditional pharmacy benefit by the year 2012.