Health Plans | Utilization Management Specialty Drug Management

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

Challenges

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.

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.

Frequently Asked Questions

How does my doctor 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; this arrangement does not require the loading of any software into the client’s or provider’s computer system.

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 reduce the time required 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 guidelines?

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.

What is included in the Specialty Drug solution?

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).

clinical expertise

At the end of the day, medicine has become so complex, and the technology has evolved so quickly, it's really hard for physicians to keep up with all the updates. I like to think that what we are doing is helping people.

Dr. Torelli

Chief of Cardiovascular Programs