What is the purpose of adjudication in the pharmacy process?

Adjudication in the pharmacy process refers specifically to the procedure of determining an insurance claim for a prescription medication. The primary purpose of this step is to establish whether the insurance plan will cover the cost of the prescribed medication and, if so, how much the patient will be responsible for paying out-of-pocket. This involves verifying the patient's insurance information, checking for any restrictions or prior authorizations required by the insurance company, and confirming the benefits associated with the specific medication being dispensed.

While aspects such as medication efficacy and assessing a patient's health needs are important in pharmacy practice, they occur in different contexts and are not directly related to the adjudication process. Additionally, while approving refills is a critical part of pharmacy workflow, it does not encompass the financial and insurance-related determinations that adjudication entails. Thus, establishing insurance coverage clearly encapsulates the purpose of adjudication in the pharmacy setting.