(21) Managed care insights on optimizing coverage coordination for therapies spanning medical and pharmacy benefits

Background: : In the biopharmaceutical landscape, certain products require coverage coordination across both pharmacy and medical benefits. One of the most common scenarios is where one or more induction doses as intravenous infusion is managed through the medical benefit followed by subsequent subcutaneous, self-administered doses that are managed through the pharmacy benefit. This could occur in a carve-in arrangement where the plan sponsor contracts with one entity responsible for covering both benefits or a carve-out arrangement where the plan sponsor contracts for each benefit separately. It is important to understand payer perceptions and challenges in cross-benefits coordination to remove potential barriers to patient access.

Objective: : To understand how payers manage therapies that require coordination across medical and pharmacy benefits.

Methods: : A web-based survey of US payers was conducted through Cencora’s Managed Care Network research panel, in February 2025.

Results: : In total, 10 advisors from health plans (70%) and pharmacy benefit managers or PBMs (30%) participated in the survey. 60% percent manage coverage coordination between health plans and PBMs through integrated software platforms and direct communication between clinical teams. For the current cross-benefit scenario (induction dose falling under medical benefit and maintenance dose falling under pharmacy), 60% require a separate prior authorization (PA) for both benefits, and 20% indicated this would vary by product type. Payers who could require separate PAs for both benefits noted physician attestation of induction therapy (63%) would be part of the PA for the pharmacy benefit maintenance therapy. Cross-coordination of benefits is a smoother process in a carve-in (50%) vs carve-out (30%) arrangement. 30% of advisors take on average less than 1 day to coordinate benefits in a carve-in arrangement compared to only 10% in a carve-out arrangement. Delays in getting required information from provider offices and submission of two PAs are identified as key challenges.

Conclusions: : Overall, advisors encounter situations that require cross-coordination of benefits. For payers, integrated cross-benefit platforms that provide access to both pharmacy and medical claims can simplify this process. Manufacturers can support payers by making them aware of the potential cross-benefit coverage requirement via pre-approval information exchange (PIE) and educating providers and office staff on navigating the PA process.

Sponsorship:: Cencora