The Evolving Medical Benefits Landscape—Are you Ready for It?

Hub Services

As published by Drug Channels Institute. Guest post from Ian Ocilka, Senior VP of Client Solutions at ConnectiveRx. Read the original article here.

The specialty pharmaceutical market is expected to reach $300 billion in 2023, an increase of over 9% a year from 2021 and accounting for over 60% of the drug spend in the U.S. when you include drugs covered by both pharmacy and medical benefits. In addition, 40% of novel drug approvals for 2021 were injectable/infusion products likely to be covered under medical benefits. The trend continues in Q1 of 2022, with 42% of approvals to date for injectable/infusion products. The continued overall growth of products covered under pharmacy and/or medical benefits will play a critical role in engaging physicians and patients and helping patients to start and stay on their specialty medications.

The best pharmacy benefits processes combine tech innovation with steps that involve real human empathy to create a streamlined electronic experience that eases the prescription journey for patients and providers. From electronic patient enrollment forms (ePEFs) to electronic benefits verification (eBV) to electronic prior authorization (ePA) and e-income checks for prescription assistance programs (PAPs), there are many elements that work in concert to make the process fast and accurate.

And while strides are being made to improve the medical benefits journey, that process currently offers a completely different experience and lags behind the pharmacy benefits process. Technology used today serves as a bridge to the eventuality of full medical electronic benefits verification (eBV)—while we do not see this as a long bridge, it is a bridge nonetheless. Stakeholders should consider the short- and long-term strategies of their patient support goals to ensure they are not left on the wrong side of the riverbank.


The current medical eBV process is intensely manual, aided by evolving electronic processes and tools. Outcomes-based case management, while not necessarily shortening the patient journey, is a philosophy that helps improve the overall patient and physician experience because of diligent follow-through by human teams who are aided by technology. Supplementing manual work with forms of medical eBV that include plan-level information and pilots of voice AI help capture the portions of the manual pieces of information without the need for an actual agent sitting in a seat.


The human and voice AI pieces of the eBV journey will soon be replaced with a true medical eBV solution. And when that becomes a reality, the industry will pivot to focus on the bookends of the eBV: the front being more effective ways to engage physicians in enrolling their patients in the hub and leveraging best practices for non-commercial pharmacy (NCP) submission by coupling an e-prescription with a medical e-eligibility check that locates a patient’s insurance information.

On the back end, voice AI will take on a new role, automating follow-up calls with payers and further strengthening outcomes-based case management. Case managers will be able to engage in more high-value interactions with physicians and patients – rather than chasing the PA or prescription outcome. They will be freed to spend more time on key patient touchpoints: researching alternative funding options, connecting them to outpatient infusion facilities for certain medical benefit drugs, coordinating injection appointments for patients on a medical drug—and also working with physicians to facilitate these activities to provide deeper support for therapy onboarding.

Provider portals will continue to have their place for certain specialties. On top of that, tools will exist such as medical ePEFs placed on a brand’s website interacting with HIPAA-compliant and secure chatbots to enroll patients, or leveraging the NCP to submit a prescription which is coupled with a medical e-eligibility check.

The industry continues to balance the right mixture of technology with human intervention in pharmacy benefit patient support, and so far, we’ve seen the successful harmonization of the two. There is no doubt the fine tuning of human and machine will continue to progress in 2022 and beyond. We must all prepare to begin again with medical benefits, filled with its own unique considerations for patient and physician needs, to ensure tech and touch provide seamless support.

To learn more about the evolving medical benefits landscape, we invite you to watch the full conversation on-demand.

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