Evernorth Medical Drug Management

Delivers a robust suite of strategies for specialty medications within the medical benefit. Our tools maximize savings for plans, reduce gaps in care, enable cost-effective clinical decision making and minimize administrative demands for physicians.

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Leveraging pharmacy expertise to tackle rising medical specialty drug costs

The rise of complex, chronic conditions are driving up specialty drug use and costs to record numbers. This spend will only continue to increase over the next three years, with 200 specialty drugs set for approval. Fragmented, disconnected drug management strategies can lead to wasted time and resources, missed opportunities and more work for health plans.

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As more drugs are administered in doctors’ offices, clinics or through home or hospital infusion, traditional specialty drug trend management tools must be leveraged on the medical benefit side to ensure patient safety and to eliminate waste.
40%
of specialty drug spend occurs on the medical benefit1

Expertise you can trust

With over 30 years of experience as a PBM, and over 25 years of Specialty Pharmacy (Accredo) experience, you can be assured our advanced clinical knowledge and organizational expertise will deliver a best-in-class review process that catches overspending that could otherwise easily be missed.

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$8 PMPM

average client savings with Evernorth's Medical Drug Management program’s minimum client savings guarantee2

Simply relying on prior authorizations alone can leave room for significant financial loss

Before paying medical drug claims, many health plans ensure an approved prior authorization is present—however many systems end there. The complexity behind specialty drug claims and the lack of system automation can often mean that the majority of medical drug claims are not checked for common errors including inappropriate billing codes, administration service codes and drug waste.

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Plans with utilization management in place but no payment integrity or dose management protection spend an estimated $5.99 PMPM more than plans that validate claims prior to payment.2

Evernorth Medical Drug Management can help

Leveraging our industry-leading pharmacy and medical expertise to take on one of the largest cost drivers.

Complex home infusion drugs and services administered concurrently

Waste reduction through optimization

Site of care steerage to high-quality, low-cost settings

Enhanced determination reduces and eliminates time patients wait for treatment

Over 400 medical drug policies ensure appropriate utilization and dosage

Prepayment review and claims edits to match against prior authorizations and validate clinical guidance

Visibility across benefits through OnePA, using integrated reporting and a single operational team to align benefit policies

Automated criteria with automated dose calculations reduce provider burden and turn-around time

Flexible choices to match your specific needs

From software or delegated services, to claims management, or rebate support—Evernorth is flexible and here to support you.

Utilization management choices

Delegated support:

Policy development / maintenance

Medical necessity review

Dose management

Communications

Timeliness and compliance support

Self manage:

Medical policy license

OnePA software license

$3.55
PMPM savings3
(achieved through delegated services)

Leading the industry in managing drug trend

Our deep clinical knowledge drives powerful results and savings across both pharmacy and medical benefits.

$100

PMPY projected savings for commercial plans6

$23K

Average savings for each site of care redirection7

20

Minutes saved per case with automated self-service offering8

$27M

Average savings from clinical protocols to ensure no waste and therapy appropriateness3

Create a flexible, integrated strategy to help you stay ahead of medical drug costs and avoid waste.

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Sources

  1. 2019 PBMI Specialty Drug Benefit Report
  2. Medical Drug Management BoB Data CY 2021
  3. Medical Drug Management BoB Data CY 2022
  4. Medical Drug Management BoB CCUM data Q42021-Q12022; results may vary, dependent on prospective client savings analysis
  5. MedRx Preferred rebate value, all lines of business, 2022
  6. 2019 Medical Drug Management Site of Care Program Performance – Client Quarterly Business Review
  7. 2020 Medical Drug Management BoB Data – QBR Savings Evaluation
  8. 2020 ESI Clinical Ops evaluation, examining OnePA system medical drug reviews compared to manual reviews of a clinician referencing clinical policy documents