Data alignment between payer benefit teams remains a challenge. Leaders need to build sustainable strategies to best understand improvements for efficiencies and member experiences.
Complex data structures require new strategies
Medical and drug benefits used to be more clean-cut, resulting in siloed teams, coding structures, and benefit designs. The system was built to accommodate clear delineations between prescription medication and medical treatments.
However, over time, drug therapies have rapidly evolved—in both scale and complexity—requiring these models to transform. Specialty drugs in the form of biologics and biosimilars, as well as GPL-1 and semaglutide products, have blurred the lines between medical and drug benefits, especially when products can be self-administered.
Additionally, different coding models and structures have complicated information sharing between teams. Pharmacy benefit teams and their systems operate with National Drug Codes (NDC) and medical benefit teams operate in condition code sets like ICD-10 for diagnoses, HCPCS for non-physician services, and CPT for medical procedures.
Challenges with drug code mapping
Tying to consistently translate between these codes at scale is a challenge. Pharmacy teams need to better understand why a provider is requesting a drug or what medical causes may be triggering a prescription. Data analysts often use crosswalks and the Medi-Span® Generic Product Indicator (GPI) to translate back and forth between medical conditions and code databases and then back into NDC codes. Billing can also be a challenge as the drug units and/or package sizes often have to be translated between the code sets and in alignment with NCPDP standards.
