Health Plans | Utilization Management Medical Drug Management

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.

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.

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, or other rare conditions. The services provided by eviCore 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; and utilization guidance to the lowest-cost, most clinically effective drug where appropriate.

eviCore’s specialty 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.

In addition, our Specialty Drug Management solution includes a library of clinical guidelines that covers a variety of therapeutic areas. Each guideline document is developed and updated by an experienced clinical team of PharmDs and physician specialists. Our developmental efforts 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.

More and more across the U.S. today, physicians are shifting the site of service of specialty drugs from their office to a hospital outpatient department, resulting in significantly higher costs for health plans and members. eviCore’s 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, eviCore empowers members to control their facility choices. In addition, eviCore acts as a concierge to the member by providing transparency into the cost of services and coordination of appointments.

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.

The eviCore 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.

Because our solution offers providers direct access to our prior authorization tool, they can usually 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 health plan for integration into their claims payment system.

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