New PBM Tackles Rx Claims Under the Medical Benefit

Most insurance programs still place provider administered medications under the medical benefit requiring that the meds be billed to the payer in the traditional claims submission process, not via the PBM. The efficiency of PBM adjudication is not at question. However, moving meds from the medical benefit to the pharmacy benefit is easier said than done. At least two big issues need to be overcome. First, most states require that a substantive change in the contract be approved by the insurance commission and that can take a lot of time. Secondly, the technology needs to be adapted to adjudicate using different reimbursement methodology that can vary from provider contract to contract.

The article below details a possible solution, one which PBMs have been talking about for more than a decade….. but have not yet delivered. TransactRx is launching a program to tackle the challenges related to claim adjudication for medical provider administered medications.

TransactRx cites an example where they have “moved 100% of specialty medications for a payer’s commercial lives from the medical benefit to the pharmacy benefit while retaining the providers’ buy-and-bill drug acquisition model and maintaining all sites of care for their patients.” That is no small feat…. if it is as simple as stated. It also requires that all providers in the ‘network’ submit standard pharmacy (NCPDP) claims, which would present major operational and technical changes for the practices.

It will be interesting to see if TransactRx is able to overcome the challenges and finally offer a sustainable alternative to traditional billing under the medical benefit.

TransactRx Launches SpecialtyXB, a better way to manage buy-and-bill medical benefit specialty drugs

MIAMI, Aug. 11, 2021 /PRNewswire/ — TransactRx announces the launch of SpecialtyXB an innovative solution for payers to move the coverage of medical provider administered specialty drugs from the medical benefit to the pharmacy benefit. TransactRx provides an integrated set of consulting services, provider network management and technology to enable medical providers across all places of service to submit claims and receive payments for provider purchased specialty drugs administered to patients. SpecialtyXB is the newest of the TransactRx cross benefit solutions that manage drug spend across medical and pharmacy benefits.

With SpecialtyXB everyone wins: Payers, Providers and Patients
Specialty medications represent nearly half of the drug spend in the US and are expected to increase by more than 11% this year. Just under 50% of the specialty drugs are administered by hospital outpatient clinics, infusion centers and medical providers that purchase the drugs and are billed under the medical benefit (a model called buy-and-bill). Over the past 10 years the PMPM dollars spent on commercial lives for these medical benefit specialty drugs is up almost 90%. The increases in medical drug spend create several challenges for payers as the utilization data is captured from batch medical claims and adjudicated on platforms that don’t have the same utilization management tools available on PBM platforms used to adjudicate pharmacy claims.

“To respond to these rising costs and management challenges some payers have started to move medical specialty drugs to a white-bagging model or a home infusion model which has decreased costs but has introduced issues with providers and with patients”, said Jack Guinan, CEO, TransactRx. “Our SpecialtyXB service provides an alternative solution that has proven to reduce costs, provide transparency to data, maintains provider relationships and supports the highest level of patient quality of care.”

SpecialtyXB is implemented on the TransactRx Cross-Benefit platform which seamlessly integrates medical and pharmacy systems to enable provider administered specialty drugs to be billed and reimbursed as standard pharmacy (NCPDP) claims. The solution includes the implementation of a medical provider pharmacy network managed by TransactRx which contracts with the payer’s PBM. The experienced TransactRx team, with over a decade of managing medical provider administered drug reimbursement, works with the payer, providers and pharmacy benefit manager to implement and operate the solution.

TransactRx successfully implemented SpecialtyXB with a regional Blue Cross and Blue Shield payer contracting with over 2700 medical providers that support their 640K commercial lives. The implementation resulted in moving 100% of specialty medications for the payer’s commercial lives from the medical benefit to the pharmacy benefit while retaining the providers’ buy-and-bill drug acquisition model and maintaining all sites of care for their patients. TransactRx is in discussions to launch SpecialtyXB with several other payers

For more information how TransactRx can help manage medical provider administered specialty drugs please visit our website

About TransactRx
TransactRx provides Cross Benefit Drug Reimbursement Solutions where everyone wins; payers, providers and patients. TransactRx has developed and operates its patented Cross Benefit Clearinghouse platform, operates national scale provider networks and provides consulting services that enable medical providers to be reimbursed for products and services covered under pharmacy benefits and enables pharmacy providers to be reimbursed for products and services covered under medical benefits.


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