Specialty Drug Management: Overview

eviCore’s Specialty Drug Management solution applies evidence-based guidelines to drive utilization management. That ensures clinically appropriate and safe use of non-oncology specialty drugs, drives drug administration to the lowest cost site of care, and drives payment integrity of medical benefit billed claims. Our tools utilize innovative technology to improve operational efficiencies, capture necessary clinical information, and enable meaningful analysis and reporting. For example, providers now receive coverage determination immediately upon completion of all relevant clinical information.


Everyone benefits through better outcomes

  • Plans

    Our Specialty Drug Management solution works collaboratively with the health plan to ensure provider adherence to evidence-based guidelines, redirect the drug infusion to a preferred site of care, and enforce the plan’s formulary.

  • Providers

    Our Specialty Drug Management solution offers providers direct access to our prior authorization tool, so they can open a case, enter patient data, answer questions, and receive a determination within 2 minutes. Treatment authorizations are issued in real time and transmitted directly to the payer for integration into their claims payment system.

  • Patients

    Our Specialty Drug Management solution provides appropriate treatment recommendations that help deliver quality and reduce out-of-pocket costs.


Criteria & Easy Approval Process: Leading To Better Decisions

Nurse Review MD Review Peer to Peer Predictive Intelligence and Clinical Decision Support Appropriate Decision Web Phone Fax Methods of Intake REAL-TIME DECISION

The more we know, the better the outcome

A list of the most common Specialty Drug Management queries are provided below. For more detailed information, visit the Contact Us page.

How will this solution impact my ability to get a specialty drug approved by the health plan?

Our Specialty Drug Management solution is designed to decrease the time it takes to get a drug approved. If the patient meets the clinical criteria, the provider will receive an instantaneous approval.

What if the request does not meet clinical criteria?

Drug requests failing to meet clinical criteria will be sent for further 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.

How does the provider access the Specialty Drug Management solution?

Providers can access the eviCore Specialty Drug Management solution via a password-secured login to the eviCore or health plan Web portal which does not require any software to be loaded into the client’s or provider’s computer/systems.