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Health Plans | Utilization Management

Medical Drug Management

With the rapid emergence of gene therapies and market-competitive biosimilars, plans need a more integrated, evidence-based approach to effectively manage the costs and complexities of medically billed specialty drugs. Going beyond utilization and claims management, Evernorth MDM leverages automation, medical drug rebate optimization, comprehensive oncology management, subspecialty physician expertise, and interconnected tools and services to reduce waste, optimize savings and improve clinical outcomes.

Learn more here and contact Evernorth at with any questions.

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Specialty medications—those medications for patients with complex, chronic conditions such as rheumatoid arthritis, multiple sclerosis, or immune-mediated conditions—are expensive. For most plans, while fewer than 1% of members use specialty medications, they typically account for 38% of total drug spending. Specialty patients also require the most personalized care and counseling because of their unique needs and complex medication regimen requirements.

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Complex Problem

Because many specialty medications are administered in doctors' offices, clinics, or hospitals, approximately half of all specialty medication spending occurs through the medical benefit. In these instances, health plans have little insight into how patients use these expensive medications and few opportunities to manage their use.

EviCore provides a simple solution to a complex problem to ensure appropriate specialty drug use at the lowest possible cost.

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Services Covered

Our solution targets more than 100 non-oncology specialty drugs covered under the medical benefit, including drugs to treat rheumatoid arthritis, Crohn’s Disease, multiple sclerosis, and other rare conditions. Services include: 

  • Utilization management to ensure appropriate use of the requested drug
  • Site-of-care redirection to a lower-cost alternative
  • Payment integrity through our proprietary Claims Studio integrated system
  • Guidance to the lowest-cost, most clinically effective drug where appropriate
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Clinical Guidelines

Utilization management determines appropriate use for more than 100 drug codes in more than 24 non-oncology disease categories. The key considerations are based on the latest clinical evidence pertaining to diagnosis, safety, genetic testing, and lower-cost alternatives. This includes a library of clinical guidelines covering a variety of therapeutic areas. Our experienced team of pharmacist and physician specialists develop and update each guideline document. We apply key standards to ensure fair and consistent decision-making, medical policy in accordance with regulatory requirements, and alignment with established industry standards as well as client expectations. 

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Site-of-Service Management

Across the U.S., physicians are shifting the site of care for specialty drugs from their office to a hospital outpatient department, resulting in significantly higher costs for health plans and members. Our innovative program serves as a provider- and patient-outreach service to steer health plan members to an alternative infusion site for their drug administration, such as a client’s contracted home-infusion or ambulatory infusion provider. By presenting lower-cost, convenient, and same-quality options, we empower members to control their facility choices. In addition, we act as a concierge for members by providing transparency into the cost of services and coordination of appointments.

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Payment Integrity

The implementation of the Claims Studio system for post-service, pre-payment claims review helps ensure that our clients pay only medical claims that have been authorized for approval and scrubbed for coding and billing errors.

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The Evernorth Medical Drug Management solution works collaboratively with health plans to ensure provider adherence to evidence-based guidelines, redirect drug infusions to preferred sites of care, and manage adherence to the plan formularies.

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Our solution offers providers direct access to our prior authorization tool, which typically enables providers to open a case, enter patient data, answer questions, and receive a determination within two minutes. Treatment authorizations are issued in real time and transmitted directly to the health plan for integration into their claims payment system.

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Our solution provides appropriate treatment recommendations that ensure quality performance levels and reduce out-of-pocket costs.

Frequently Asked Questions

Providers can access our solution via a password-secured login to the EviCore or health plan web portal. They do not require any additional software.

Our solution is designed to reduce the time required to get a drug approved. If the patient meets the clinical criteria, the provider will receive an instantaneous approval.

Specialty drug requests that fail to meet clinical criteria are sent for an additional review by one of our medical directors. Based on the information from the requesting provider, our 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).

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