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Specialty Pharmacy Care Management Program

We put you and your members in control with our unique, high-touch programs

Specialty pharmaceuticals are true "wonder drugs," but treatment with them is often wide-ranging—and expensive. We help your members achieve the very best outcomes, while helping you manage costs, though a comprehensive, high-touch combination of personalized products and services.

Our high-touch, patient-centric Specialty Care Management Program provides a seamless member experience by helping to ensure appropriate medication utilization and medication compliance, offering targeted condition education and Disease Therapy Management, offering your members support and education for controlling side effects, and offering specialized handling and distribution of medications.

In addition, our program is supported by our Client Services team

Your goals are our goals. Our team of pharmacy benefit and pharmaceutical industry experts is wholly dedicated to helping you achieve your plan performance goals.

Our Account Managers, Clinical Account Managers/Directors and an experienced Account Management leadership team work together seamlessly to assist you with all of your needs, including:

  • Analyzing plan performance and providing plan design consultation
  • Offering trend and pricing analysis and insights
  • Working with you to develop and execute strategies for promoting pharmacy benefit programs to your members
  • Keeping you informed about formulary and clinical program changes, as well as the pharmaceutical pipeline and industry happenings

Specialty Care Management Program Overview

Our URAC-accredited specialty pharmacy program goes beyond the prescription: We offer a comprehensive Specialty Care Management Program that will enable your members to achieve optimal outcomes from their specialty medication therapies while helping you effectively manage costs. We offer nearly 400 medications across 25 therapeutic categories and specialty disease states. Learn more about our Specialty Care Management Program:

The cornerstones of this comprehensive program are:

Utilization Management Program

  • Personalized case review and managed prior authorizations
  • Step therapy
  • Quantity dose review
  • Dose optimization
  • Drug Utilization Review (DUR)
  • Co-pay assistance program referrals

Utilization management evaluates the appropriateness, clinical need and efficiency of prescription medications, based on established criteria or guidelines. We integrate utilization management components into all aspects of our specialty pharmacy operations. Our utilization management programs aim to provide outreach, education, and comprehensive guidance to physicians on national, peer-reviewed guidelines. These programs include:

  • Personalized case review and prior authorization
  • Step therapy
  • Co-pay assistance referral programs

Personalized Case Review and Prior Authorization

We offer comprehensive case review and prior authorization (or pre-certification) services that serve as an integral part of the overall clinical management and cost management of specialty medications.

We work with clients directly to determine medical necessity requirements, adapt our existing guidelines to meet client needs, and incorporate plan-specific criteria as necessary. We are able to accept partial or full delegation for utilization management through application of case review and authorization procedures. We can also accommodate processes for partnering with the client or the client's medical vendors to coordinate authorization. For example, we can work directly with health plans to communicate authorization requests and obtain plan approval prior to dispensing.

Case review is a highly recommended process to promote appropriate medication use that is consistent with the benefit. Case review is an integral part of the overall clinical management and cost management. Case review is accomplished through a dedicated team of nurse care managers, registered pharmacists, and Pharm.D.s interacting by phone or fax with the requesting physician offices. If the request is for an eligible member and is for a covered service, it is reviewed using evidenced-based guidelines. A clinical pharmacist renders all specialty medication case review decisions.

We also support development of clinical recommendations on appropriate guideline criteria and communication of industry updates as new drug therapies arrive on the market or new evidence-based literature indicates the need for a change in criteria.

Case review and authorization services offered through our organization are accomplished through a dedicated team of licensed pharmacists and pharmacy technicians who interact via phone or fax with physician offices and/or client or health plan contacts.

Step Therapy

One of our key clinical management techniques is step therapy. This drug utilization review strategy focuses on specific drugs and drug classes to promote utilization of effective, safe, and less costly first-line medications. Ultimately, this strategy helps encourage improved member behavior patterns and awareness of appropriate drug use, and influence physician prescribing patterns.

We can apply our step therapy guidelines through contingency edits and prior authorization. Programming for contingency edits is included in our administrative fee. Application of step therapy via prior authorization will incur a charge per authorization. We work with clients to recommend the most clinically appropriate and cost-effective means of implementing step therapy.

Co-Pay Assistance Referral Program

Continuity of therapy is crucial with specialty medications. In order to avoid interruptions in drug therapy, we can refer qualified members to programs that offer co-pay assistance. Programs that offer support include pharmaceutical manufacturers, HealthWell Foundation® and Patient Access Network Foundation® (PAN).

Collaborative Prescription Fulfillment Program

  • Phone-based outreach and coordinated next-day deliveries for member convenience
  • Deliveries at the member’s location of choice, either home or a provider’s location
  • Free supplies (when appropriate)

Working directly with the patient, caregiver or provider to ensure that medications are delivered as scheduled and temperature controlled to ensure proper administration is at the heart of our prescription fulfillment program.

  • Coordinating the shipment to the member's location of choice
  • Providing temperature controlled, next-day delivery at no additional cost
  • Tracking shipments proactively to ensure successful delivery
  • Emailing delivery notifications directly to select users when a delivery attempt has been made and delivery does not take place
  • Distributing patient educational materials
  • Providing ancillary supplies (sharps container, bandages, gauze, alcohol swabs, needles) with each order at no additional charge

Medication Compliance Program

  • Proactive refill reminders by phone to encourage compliance
  • Provider is alerted if compliance issue is identified

Medication compliance is crucial to the effectiveness of a member's treatment program for a chronic disease. Our medication compliance program helps patients stay on track with their physician's prescribed medication regimen.

Our patient care coordinators call the member prior to each scheduled refill and coordinate his or her next prescription delivery. Up to three phone attempts are made prior to the member's scheduled refill date. If we are unable to reach the member though these calls, we place a follow-up call one week after the scheduled refill. We then notify the member's physician if there is no contact or follow-up from the member.

Condition Management and Education Program

  • Free educational materials sent to members and providers
  • Newsletters available for certain conditions
  • Information available on website
Member education is a key part of a successful specialty pharmacy program. Well-informed members can better manage their chronic conditions, and are more likely to adhere to therapy and make healthy lifestyle choices. This can result in improved member outcomes and satisfaction and reduced catastrophic medical events, absenteeism, and overall health care costs. Curriculum currently consists of over 20 conditions or medication based education topics.

Clinical Management Program - Disease Therapy Management

  • Available for Hepatitis C, Rheumatoid Arthritis and Multiple Sclerosis
  • Free phone consultations with our trained clinicians
  • Individualized care plan
  • Ongoing case management and follow-up with member

Our Clinical management program provides structured educational and clinical support for patients to help improve adherence, appropriate utilization, and ensure optimal outcomes. Our Clinical Management Programs are a value-added program, available to clients and members at no additional cost.

Disease Therapy Management Program Overview

The Disease Therapy Management (DTM) program is designed to help patients remain compliant with their medication therapy through individualized support, communication and education on targeted disease states, enhancing their health and wellness. We currently support DTM programs for hepatitis C, multiple sclerosis, and rheumatoid arthritis.

Patient Services

The DTM program services for patients include, but are not limited to, the following:

  • One-on-one phone consultations with a registered nurse or clinical pharmacist
  • Personalized care plans highlighting the key issues discussed during the consultations
  • Management tips on symptoms related to the medical condition
  • Management tips on side effects of drug therapy
  • Monthly educational materials related to the medical condition
  • Reference for additional resources
  • Prospective refill reminder calls and follow-up calls during the subsequent month
  • Proactive identification and intervention for at-risk members for medication non-adherence.

Provider Services

The DTM program services for providers include, but are not limited to, the following:

  • A care plan which highlights key issues discussed during the consultations
  • Provider awareness of patient condition and progress within the DTM program through the care plan mailings

Program Benefit

Our DTM strategy is straightforward: to design and implement actionable pharmacy-based interventions for patients taking select specialty medications to treat high-cost, high-impact conditions. Targeted conditions currently include:

  • Hepatitis C
  • Multiple sclerosis
  • Rheumatoid arthritis

These three disease states represent the top three categories of specialty medications, in terms of overall cost, emergency room visits, and hospital stays. By targeting these key conditions, we can offer clients enhanced, focused management of top-risk member populations and maximize savings across both the pharmacy and medical benefit.

The overall program goals are to improve quality of life, promote self-management, improve medication adherence, and reduce overall health care costs in managing chronic illness.

We measure the impact of our disease therapy management programs by evaluating pharmacy and medical utilization and cost data, as well as health outcomes related to medication adherence, quality of life, work productivity, work presenteeism/absenteeism, and functional status. Our measurement techniques rely on industry-recognized tools for measuring these outcomes, such as the SF-12v2™ Health Survey and the Centers for Disease Control (CDC) Healthy Days Core Module (CDC HRQOL-4).

Program Duration

The DTM program is a seven-month program, with an extension period of three months for patients requiring additional support; on a case-by-case basis, we can extend this even longer if necessary. During the seven-month period, patients will be provided with resources that are helpful in managing their health and medication therapy.


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