WASHINGTON — In a move aimed at expanding patient access to care and enhancing health outcomes, the American Pharmacists Association (APhA) today released a new set of recommendations to help integrate pharmacists' clinical services into health plan medical benefits.
Titled “Recommendations for Health Plans and Pharmacists to Advance Coverage for Pharmacists' Services in the Medical Benefit,” the guidance document lays out 11 key strategies to support collaboration between pharmacists and health plans. The recommendations stem from a yearlong learning collaborative that brought together stakeholders from the healthcare landscape — including pharmacy professionals, insurers, and quality organizations — to share real-world experience and best practices.
“Activating pharmacists' medication and health-related expertise facilitated by coverage for services in the medical benefit is a win-win for patients, health plans, and the health care system,” said Brigid Groves, PharmD, MS, APhA vice president of professional affairs. “These recommendations serve as a road map for health plans and pharmacists to collaborate on building sustainable models that recognize the value pharmacists bring to the health care system.”
The guidance comes as more state Medicaid and commercial health plans begin recognizing pharmacists as medical providers. This shift allows pharmacists to offer patient care services, such as medication management, chronic disease support, and preventative care, under the medical benefit, rather than only through pharmacy benefits.
However, the transition is complex. For pharmacists to fully participate, they must go through processes typically required of other healthcare providers: credentialing, contracting, enrollment, billing, and regulatory compliance. The new recommendations provide actionable steps to ease this transition and foster mutual understanding between payers and providers.
The document also includes case studies highlighting organizations' challenges and successes when implementing these models, offering practical insight for others seeking to follow suit.
APhA encourages health plans and pharmacists to use the recommendations to form innovative partnerships and ensure patients benefit from the full range of pharmacists' expertise.
The full report is available online at pharmacist.com.
