WASHINGTON, DC (April 21, 2025) — The American Pharmacists Association announces the release of Recommendations for Health Plans and Pharmacists to Advance Coverage for Pharmacists’ Services in the Medical Benefit. The recommendations are designed to improve patients’ access to care and health outcomes by expanding coverage for pharmacists’ patient care services under health plans’ medical benefits.
The recommendations are the result of a yearlong learning collaborative composed of thought leaders from health plans, pharmacy practices, and quality organizations who are actively engaged in implementing payment programs for pharmacists. Participants in the learning collaborative brought real-world expertise to the development of these recommendations and represent a range of practice settings and payer organizations. Their work provides a critical bridge between policy and practice, offering actionable steps supporting pharmacists' integration as care providers within medical benefit structures.
Increasingly, state Medicaid and commercial health plans are recognizing pharmacists as medical providers and providing coverage for their patient care services under the medical benefit. To include pharmacists in their provider networks, health plans must initiate processes for pharmacists to contract, enroll, credential, bill for services, and comply with other plan requirements. Pharmacists, who enroll with health plan(s) as an individual provider, must navigate new processes and expectations associated with being a covered network provider. The 11 recommendations cover a wide range of topics to facilitate uptake, from needed policy changes to various coverage implementation strategies, and include examples of experts’ successes, challenges, and barriers.
“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.”
APhA encourages health plans and pharmacists to utilize the recommendations as a guide for implementing innovative partnerships and coverage strategies that improve access to care and health outcomes.
The full document is now available on the APhA website at https://www.pharmacist.com/practice/coveragepayment.