Overview
A member's health plan has two separate benefit structures: the medical benefit, which Yuzu adjudicates, and the pharmacy benefit, which the pharmacy benefit manager (PBM) adjudicates. The distinction generally comes down to how the item or service is billed, rather than the item itself:
Medical claims: Submitted by providers through medical billing (837 claims) and adjudicated by Yuzu
Pharmacy claims: Submitted by pharmacies through the pharmacy point-of-sale system (NCPDP) and adjudicated by the PBM
The same item can fall under either benefit depending on how it is dispensed and billed. Although medical and pharmacy claims are processed separately, both may contribute to a member's deductible and out-of-pocket accumulators.
Pharmacy-Dispensed Items
Items dispensed and billed through a pharmacy generally process under the pharmacy benefit, including prescription drugs and certain medical devices or supplies.
Common examples include:
Prescription medications
Diabetic testing supplies
Continuous glucose monitors (CGMs)
Certain durable medical equipment (DME)
Even if an item is considered medical equipment, it may still be covered under the pharmacy benefit when billed through the PBM. For example, a CGM dispensed through a retail pharmacy may process under the pharmacy benefit, while the same device supplied by a medical equipment provider may process under the medical benefit.
Important: Coverage ultimately depends on the plan's benefit configuration. An item being billed through a pharmacy does not automatically mean it is covered.
Routing Pharmacy Questions to the PBM
The PBM is responsible for adjudicating pharmacy claims, including determining coverage, pricing, and member cost sharing. Questions that should generally be directed to the PBM include:
Formulary coverage: Whether a medication is covered under the plan
Drug tiering: Which tier a medication falls under and how that affects cost sharing
Prior authorization: Whether a medication requires approval and why a request was approved or denied
Quantity limits: Restrictions on how much medication can be dispensed
Pharmacy pricing: Why a prescription processed at a certain price or was rejected at the pharmacy
Yuzu does not directly adjudicate pharmacy claims and cannot override the PBM's adjudication decisions.
What Yuzu Can See
Although Yuzu does not adjudicate pharmacy claims, it receives pharmacy claims data from the PBM through periodic claim file transfers. Once these claims sync into Yuzu, they can be viewed alongside medical claims.
Pharmacy claim records generally include:
Claim number and prescription information, including the drug's NDC
Member cost sharing, including deductible, copay, and coinsurance
Plan-paid amounts
Adjudication information reported by the PBM
A few things to note:
Adjudication: Pharmacy claim amounts are derived from the PBM's file data rather than calculated by Yuzu. Synced claims are not repriced through Yuzu's normal adjudication process, although pharmacy claims can be uploaded manually.
Claim visibility: Pharmacy claims only become visible in Yuzu after the PBM's claim file has been received and processed
Duplicate claims: Yuzu's duplicate-checking logic can also consider pharmacy claims. If an item was already paid through the PBM and then billed under the medical benefit, it may be flagged as a potential duplicate for review
How Pharmacy Claims Affect Accumulators
Medical and pharmacy benefits may share a member's deductible and out-of-pocket maximum, depending on the plan's configuration. Yuzu and the PBM exchange information to keep the member's accumulator balances aligned.
1. Pharmacy Claims Sync Into Yuzu
When pharmacy claims are received from the PBM, Yuzu applies the reported member cost sharing to the appropriate accumulator. Each benefit tier is assigned to an accumulator through its configuration. The pharmacy benefit tier may:
Share an accumulator with medical benefits: Pharmacy and medical spending contribute toward the same deductible and/or out-of-pocket maximum
Use a separate pharmacy accumulator: Pharmacy spending accumulates independently from medical spending
2. Medical Accumulator Data Is Sent to the PBM
Yuzu also sends scheduled accumulator files to the PBM, communicating members' deductible and out-of-pocket progress. For plans with shared accumulators, this allows the PBM to account for medical spending when determining pharmacy cost sharing.
Because pharmacy claims and accumulator files sync on separate schedules, balances may not update immediately. Pharmacy spending may take time to appear in Yuzu, while medical spending may not reach the PBM until the next scheduled file transfer.