Pharmacy & Therapeutics
Where the Drug Meets the Care Setting
Home infusion, specialty pharmacy, buy-and-bill economics, biosimilars and stewardship. The drug is only half the problem. Who buys it, which benefit pays, and where it gets administered decide whether the patient actually receives it.
Pharmacy & Therapeutics Coverage Areas
Eight domains, ordered from the site-of-care shift outward. Home infusion and specialty pharmacy sit first because they are where the post-acute drug story actually happens.
Home Infusion & Site-of-Care Shift
Antibiotics, biologics, chemotherapy and parenteral nutrition that once required an inpatient bed or an outpatient chair are moving into the home. Medicare's permanent home infusion therapy benefit pays the professional services separately from the DME pump, and payer site-of-care programs keep steering infusions out of the hospital outpatient department.
Specialty Pharmacy
Limited-distribution networks, benefits investigation, prior authorization, copay assistance and hub services all sit between a prescription and a first dose. For a discharge planner this is the step that decides whether the patient goes home with the drug in hand or waits two weeks on a pending authorization.
Part B Buy-and-Bill vs Part D
Which benefit pays changes who buys the drug, how it is priced, and what the patient owes. Part B pays the provider who purchases and administers the drug, based on average sales price plus a statutory add-on. Part D runs through a plan formulary and a pharmacy. The same molecule can sit on either side depending on how and where it is given.
Biologics & Biosimilars
Biosimilar uptake is a contracting and site-of-care question as much as a clinical one. Interchangeable status under the BPCIA allows substitution at the pharmacy counter without prescriber intervention, while provider-administered biologics compete on acquisition cost and the Part B add-on.
FDA Approvals & Drug Launches
New approvals, label expansions, accelerated approvals, complete response letters and shortages all change protocols across every setting. NewsHX covers approvals here, as a therapeutics and access story. TechHx keeps the device, diagnostic and platform side of the FDA pipeline.
340B Drug Pricing Program
Covered entities buy covered outpatient drugs at the 340B ceiling price and keep the spread. Contract pharmacy arrangements, manufacturer rebate models and duplicate-discount rules are now the most litigated part of US drug distribution, and the program is large enough to move hospital margins on its own.
Medication Management & Deprescribing
Reconciliation at every transition, and a deliberate deprescribing plan for the patient arriving at the SNF on fifteen drugs. Polypharmacy is among the most common avoidable harms in post-acute care, and reconciliation is the step most often skipped when a discharge is rushed.
Antimicrobial Stewardship
CMS conditions of participation require antibiotic stewardship programs in hospitals and in long-term care facilities. Post-acute is where stewardship is thinnest and where resistant organisms concentrate, which makes the program a survey item and an infection-control reality at the same time.
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Figures are quoted with their vintage rather than rounded forward. The NHIA patient count comes from its 2020 Infusion Industry Trends report and is the most recent association-published national estimate we could verify. Specialty share of spend is IQVIA Institute analysis as reported in payer and GPO outlooks.
Site of Care: Where the Infusion Happens
The same infusion costs three different amounts and is bought by three different parties depending on where it is given. This is the structure behind every site-of-care steering decision, every payer policy that moves a patient out of the hospital outpatient department, and every home infusion referral that does or does not stick.
The hospital buys the drug, at the 340B ceiling price where the entity qualifies.
Outpatient Prospective Payment System. Separately payable drugs are paid at average sales price plus the add-on; low-cost drugs are packaged into the procedure.
Clinical acuity, first-dose safety and rescue capability. Payer site-of-care policy pushes everything else out.
The practice buys and bills the drug itself, carrying the inventory and the credit risk.
Physician Fee Schedule. The drug is paid at average sales price plus the add-on, with a separate administration code.
Chair capacity, acquisition cost, and whether the add-on covers the carrying cost of an expensive biologic.
A home infusion pharmacy dispenses the drug and supplies; the external pump is durable medical equipment.
Part B home infusion therapy services benefit for the professional services, paid separately from the DME pump and the drug.
Patient stability, whether an infusion nurse is available, and whether the drug's administration method and duration qualify under the benefit.
Benefit category, packaging thresholds and add-on percentages are set per drug and per setting, and sequestration reduces the add-on actually paid. Confirm current policy before applying any of this to a specific case.
The same drug can land on either side. Where it lands decides who buys it and what the patient owes.
| Medicare Part B | Medicare Part D | |
|---|---|---|
| Typical administration | Given by a clinician: hospital outpatient, physician office, dialysis facility, or the home through a DME pump. | Self-administered and dispensed by a retail, mail or specialty pharmacy. |
| Who acquires the drug | The provider purchases the drug and bills for it after administration — buy-and-bill. | The pharmacy dispenses against the plan's benefit; the plan and the PBM sit on the price. |
| How it is priced | Average sales price plus a 6% statutory add-on, published quarterly by CMS. | Plan-negotiated price inside a formulary, with rebates flowing behind it. |
| Patient cost sharing | 20% coinsurance after the Part B deductible, with no annual out-of-pocket maximum. | Plan cost sharing, capped at $2,100 out of pocket in 2026 under the Inflation Reduction Act redesign. |
| Utilization management | Local and national coverage determinations, medical necessity review, and prior authorization in Medicare Advantage. | Formulary tiers, step therapy, quantity limits and prior authorization. |
Benefit category is set per drug and per administration method, and Medicare Advantage plans layer their own rules on top. Confirm against current CMS policy before acting on a specific case. The negotiation and pricing-reform side of this lives in Policy.
Devices, diagnostics and the university pipeline
Drug approvals are covered here. TechHx keeps 510(k) and PMA device clearances, diagnostics, rehab technology and the tech transfer offices where the molecules start.
Drug pricing reform and the Inflation Reduction Act
Negotiated maximum fair prices, the Part D redesign and formulary rulemaking are tracked as policy. The operational consequence for a care team is tracked here.