Managing the Medical Benefit

Today’s health care system centers on delivering the right medicine to patients in their times of need. In a global sense, those medicines are offered to patients through either their medical benefit or their pharmacy benefit. In a logistical sense, they are delivered to patients at the pharmacy, or administered to them by health care professionals in their clinics.

By the end of this module, you will be able to:

  • Identify how the design of the medical benefit makes drugs available to patients
  • Contrast the differences between medical and pharmacy benefit designs related to a patient’s share of cost
  • List the methods employed by MCOs to manage the cost of providing drugs to beneficiaries
  • Recognize the individual roles of stakeholders within MCOs
  • Formulate call strategies to influence stakeholder decisions
  • Contrast how pharmacy benefit drugs are distributed compared to medical benefit drugs
  • State how all these factors influence the decision to administer drugs to patients in the provider’s clinic