The Specialty Pharmacy Evolution: Succeeding in the Shift to Medical Benefit Pathways

Specialty pharmacy is no longer a niche segment; it’s one of the fastest-growing and most profitable areas in healthcare. Most importantly though, specialty medications, often used to treat complex, chronic, or rare conditions such as cancer and autoimmune diseases, have transformed patient outcomes and reshaped the role of the pharmacy in the care model. For many pharmacies, offering specialty medications is a strategic move that opens the door to:

• Expanded revenue streams from higher-value therapies
• Stronger provider partnerships and more collaborative care
• Long-term patient relationships with populations relying on trusted providers
• Differentiation in a competitive market through advanced clinical services

In short, specialty pharmacy represents a growth engine with the potential to improve financial performance and patient care.

But this opportunity comes with a significant shift; one that’s changing the rules of the game.

From Pharmacy Benefit to Medical Benefit: A New Set of Challenges

Traditionally, most prescriptions are billed under the pharmacy benefit, using processes and systems designed for retail dispensing. However, specialty medications—particularly injectable, infusion, or biologic therapies administered in a clinical setting—are increasingly reimbursed through the medical benefit pathway.

This shift brings unique challenges for pharmacies, especially those accustomed to the streamlined workflows of pharmacy-benefit billing. Under the medical benefit pathway, pharmacies must navigate:

1. High costs and limited coverage – Specialty drugs often have five- or six-figure price tags, with insurers placing them in higher cost-sharing tiers. Patients face considerable out-of-pocket expenses, and coverage may be limited to select formulary tiers, often requiring prior authorization or appeals.
2. Prior authorization (PA) and step therapy requirements – Medical benefit claims frequently require lengthy approval processes, delaying treatment. Step therapy protocols can further complicate access and increase administrative workload.
3. Complex billing procedures – Unlike the standard NCPDP format for pharmacy claims, medical benefit billing requires navigating HCPCS, CPT, and NDC codes, often with payor-specific rules. This dual-billing environment increases the risk of errors and delays.
4. Inconsistent payor policies – Each insurer may have different coverage rules, documentation requirements, and reimbursement rates, creating a moving target for billing teams.
5. Coordination of benefits (COB) – For patients with multiple insurance plans, determining primary versus secondary responsibility is complex, particularly when one payor covers the drug under the medical benefit and another under the pharmacy benefit.
6. Frequent denials and appeals – Medical benefit claims for specialty drugs are prone to denials due to incorrect coding, incomplete documentation, or failure to meet coverage criteria.
7. Underpayment for infusion and administration services – Even when the drug cost is reimbursed, associated administration services are often undercompensated, creating financial strain for pharmacies.
8. Limited visibility into claim status – Without real-time updates, pharmacies may not know whether a high-cost claim is on track for payment until delays have already impacted cash flow.

Overcoming these operational and financial challenges is essential for pharmacies looking to expand into or grow within the specialty space.

Why Purpose-Built RCM Is Critical for Specialty Pharmacy Success

Traditional pharmacy billing solutions weren’t designed for the demands of medical benefit reimbursement. Specialty pharmacy requires a revenue cycle management (RCM) approach built specifically to manage the complexity, cost, and compliance needs of high-value therapies.

A purpose-built RCM solution should:

• Integrate seamlessly with existing pharmacy workflows so teams don’t have to leave their primary dispensing systems to process medical benefit claims
• Automate benefit verification in near real-time, allowing pharmacies to confirm eligibility, coverage, and expected reimbursement before dispensing
• Apply robust coding intelligence to match NDCs, CPT, and HCPCS codes accurately and in compliance with payer rules
• Streamline prior authorization by automating submissions, tracking status, and flagging issues before they cause delays
• Enable proactive denial management with workflows that automatically identify the root cause of denials and, when possible, initiate corrective action or appeals without manual intervention
• Consolidate billing across benefit types—pharmacy, medical, and cash—so pharmacies have a unified view of revenue performance
• Provide actionable analytics and reporting for financial forecasting, payor performance analysis, and operational efficiency

How XiFin Helps Pharmacies Thrive in the Medical Benefit Landscape

At XiFin, we understand pharmacies’ shift to medical benefit billing presents opportunities and challenges. As the long-standing leader in pharmacy medical billing, our RCM capabilities are designed to manage high-cost drugs and clinical services under the medical benefit pathway.

Here’s how XiFin empowers pharmacies to succeed:

• End-to-End Medical Benefit Billing – From real-time eligibility verification to compliant claim submission, XiFin integrates with your pharmacy management system to keep workflows intact while optimizing claim accuracy.
• Advanced Coding Intelligence – Our system applies extensive proprietary edits to ensure codes are correctly matched and claims are clean before submission.
• Automated Prior Authorization & Denial Management – We accelerate approvals, reduce administrative burden, and proactively trigger appeals when necessary, helping prevent revenue leakage.
• Exception-Based Workflow Automation – Instead of manually reviewing every claim, your team focuses only on those needing attention. Clean claims flow through automatically, increasing efficiency and reducing labor costs.
• Comprehensive Accounts Receivable (AR) Management – XiFin provides real-time visibility into claim status, outstanding balances, and reimbursement timelines.
• Robust Financial Integrity – Our RCM solution is built to support GAAP, FASB, and Sarbanes-Oxley compliance. Its monthly automated reconciliation ensures accuracy and transparency.
• Integrated Data & Analytics – From payor trends to reimbursement forecasting, XiFin delivers the insights pharmacies need to make data-driven decisions that protect margins and improve cash flow.

The Bottom Line

Specialty pharmacy offerings are expanding, and the move to medical benefit billing is reshaping how pharmacies must operate to capture this growth. Those who can master the complexities of coding, benefit verification, prior authorization, and payor policy navigation will be best positioned to serve high-value patient populations, strengthen provider relationships, and drive sustainable revenue.

With the right RCM solution—one purpose-built for the demands of specialty medications under the medical benefit pathway—pharmacies can transform these challenges into a competitive advantage.

By combining intelligent automation, robust compliance, and real-time financial visibility, XiFin continues as the industry leader helping pharmacies secure the reimbursement for that is due for the products and services they offer while delivering the highest level of patient care.

Ready to see how XiFin empowers specialty pharmacies to thrive in the medical benefit era? Explore how we serve specialty pharmacies.