Insurance Basics

Sep 2, 2025

INSURANCE BASICS

By Alisa Redmon

Whether we are seasoned Biologic Coordinators, or Medical Assistant/other staff being tasked with the responsibility of biologics, having a competent understanding about how insurance works is vital to the job. Majority of the time, we work with the pharmacy benefits, though there are instances that we will deal with the medical benefit of a health plan. It is important to know and understand the difference between medical health insurance and pharmacy/prescription insurance coverage.

Medical health insurance covers healthcare services, including hospital visits, surgeries, preventative care, outpatient services, etc. The medical benefits pay the doctors and facilities where services are rendered.

Pharmacy insurance specifically covers prescription medications prescribed by providers. The pharmacy benefits pay the pharmacies where medications are filled. Prescription coverage is facilitated by Pharmacy Benefit Managers (PBMs).

The pharmacy benefit provider is rarely ever the same as the medical benefit provider. This is important to know not only for you, but to explain to patients as well as this is not generally common knowledge if you don’t work with insurance.

Understanding Insurance Cards:

Some insurance cards will have the pharmacy benefit information on them (Rx BIN, Rx PCN, Rx GRP):

Some patients receive an entirely separate card for their prescription coverage:

What do these values mean??

Rx BIN: identifies the insurance plan for pharmacy claims

Rx PCN: used by pharmacies to process claims correctly

Rx GRP: identifies the specific pharmacy benefit plan

When all else fails: contact the patient, the patient’s local pharmacy, or the Pharmacy Help Desk number on the back of the card.

When you have worked in a particular area or a specific office for a matter of time, you will eventually pick up on what pharmacy benefit plans are contracted with what medical health plans (with exceptions).

Examples:

Tricare’s pharmacy benefits are with ExpressScripts; this has not changed in years.

Blue Cross and Blue Shield has thousands of different plans all around the country. Sometimes, you can tell by the prefix of the member ID who the pharmacy benefit plan is; but in some cases an employer has chosen to go with a different plan for prescription coverage.

⭐Pro Tip: Keep a spreadsheet of the plans that are consistently contracted with the same PBM. (Include the pharmacy benefit information, PA department or provider line numbers and fax numbers). This will come in handy, as it is not always common practice for offices to obtain prescription card information from patients.

Medicare vs. Medicare Advantage vs. Medicare Prescription Drug Coverage

	Medicare	Medicare Advantage
Card Type	‘Red, White, & Blue card’	Varies
Administration	Federal government	Private insurance companies
Prescription Plan	Part D (standalone)	Part D (bundled)

Medicare Medicare Advantage Card Type ‘Red, White, & Blue card’ Varies Administration Federal government Private insurance companies Prescription Plan Part D (standalone) Part D (bundled)

The red, white, and blue card will never have pharmacy coverage information on i

Part D is a federal program offering prescription drug coverage through private insurance companies, available to anyone enrolled in Medicare Part A and/or Part B. There are two types of Part D plans:

Standalone Prescription Drug Plans (PDPs) provide prescription drug coverage only and are designed for individuals who have original Medicare (A & B), but do not have drug coverage. Examples: Aetna Medicare Rx, Cigna-HealthSpring Rx

Medicare Advantage Plans with Drug Coverage (MA-PDs) combine Medicare Part A and Part B with Part D into one plan, and often include additional benefits like vision and dental coverage. Examples: UnitedHealthcare Medicare Advantage, BCBS Medicare Advantage, WellCare Medicare Advantage

Learning and adapting to your area’s common coverage will help streamline your process when you need to begin the initiation process for a new biologic patient. It is crucial for efficiency to not only understand the differences between insurances, but also possess the ability to navigate your resources to solve the “prescription coverage mystery.”

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At BC Educators, we are dedicated to empowering biologic coordinators, healthcare professionals, and patient advocates with the education, tools, and resources needed to optimize patient care. From expert-led webinars to hands-on training, we provide comprehensive support to help you navigate the ever-evolving landscape of specialty medications and prior authorizations.