Challenges of Integrating Pharmacy and Medical Benefits | PBMI 2025

Drugs approved for at-home administration are becoming more common, which can complicate the review process due to differences in pharmacy and medical benefits within health plans.

Programs on the medical side are typically more complicated than programs on the pharmacy side, which leads to specific challenges for health systems looking to integrate. There are also different terms used in each area, according to Nishi Goel, Pharm.D., vice president of customer experience, Agadia.

“On the on the pharmacy side, they might call it a ‘quantity limit,’ but on the medical side, they might call it ‘waste management,’” Goel said in a recent video interview with Managed Healthcare Executive.

For plans looking to integrate their medical and pharmacy benefits, Goel recommends that pharmacists be included in the process to develop and review criteria.

Goel presented today at the Pharmacy Benefit Management Institute’s 2025 conference, held this week in Orlando, Florida. Her session was titled, ‘Streamlining Utilization Management for Medical Benefit Drugs.’