Drug requests failing to meet clinical criteria will be sent for an additional review by an EviCore medical director. Based on the information from the requesting provider, an EviCore medical director will render a final determination, or refer the process back to the health plan for final determination.

A specialty drug managed by EviCore will entail some or all the following attributes:

• Prescribed for a person with a complex or chronic medical condition, including rare or orphan diseases
• Requires healthcare-professional administration (medical benefit only)
• Requires additional patient education, adherence, and support beyond traditional dispensing activities
• Carries a high monthly cost (typically over $1,000/month).