In-Office Medication Administration vs. Pharmacy Fills: How Costs Work

Where and how you receive a prescription medication directly affects how your claim is processed and what you pay out-of-pocket.

In-Office Medication Administration (Medical Benefit)

When a physician or healthcare provider supplies and administers a medication to you directly during an office visit, outpatient procedure, or clinic appointment:

• Billed as a Medical Service: The medication is billed as a medical procedure through your medical benefits, not your pharmacy benefits.
• Cost-Sharing Rules: These charges are subject to your plan's standard medical deductible and coinsurance, rather than fixed prescription copays.
• Does Not Apply to Pharmacy Deductibles/Out-of-Pocket Limits: Payments made for in-office administered drugs count toward your overall medical deductible and medical out-of-pocket maximum.

Prescription Pharmacy Fills (Pharmacy Benefit)

Medications picked up at a retail pharmacy, delivered via mail order, or processed through your Pharmacy Benefit Manager (PBM):

• Billed as a Pharmacy Service: Processed directly through SmithRx (Sana's Pharmacy Benefit Manager) using your prescription card details.
• Cost-Sharing Rules: Covered under fixed prescription copays or pharmacy coinsurance according to your plan's formulary tier.

Prior Authorization Requirements for Pain Injections

Plans effective before 11/1/26

Prior authorization requirements for pain injections may vary. Refer to your Summary Plan Description (SPD) to confirm whether prior authorization is required.

Plans effective on or after 11/1/26

Pain injections require prior authorization (PA) before receiving treatment. Your provider is responsible for submitting the prior authorization request for review.

Not sure which requirements apply to your plan? Sign in to your Sana account and review your Summary Plan Description (SPD) to confirm your plan's prior authorization requirements.

How to Lower Your Out-of-Pocket Costs Using SmithRx

If your provider recommends a medication that requires administration, you have options to process it under your pharmacy benefits:

1. Ask Your Provider for a Prescription: Have your provider write a prescription for the medication rather than pulling it from their in-office stock.
2. Have SmithRx Ship Directly to Your Doctor: SmithRx can fill the prescription under your pharmacy benefits and ship the medication directly to your provider's office in advance of your appointment for administration.
3. Explore Self-Administration: Ask your licensed provider if a self-administered alternative (such as home self-injection or an oral medication) is safe and appropriate for your treatment.