Pharmacy Information for Providers
We look at our members holistically; offering coordinated medical and pharmacy benefits to help close gaps in care and improve members’ overall heath. Our goal is to help improve your patients’ health outcomes by combining medical, pharmacy and lab data ensuring coordination of our people, programs and knowledge.
Featured Videos
As a clinician, you play a powerful role in ensuring your patients are adherent to their medication regimens. Motivating your patients to adhere to their medication can contribute to improved outcomes and increased STARS performance. We created these videos to offer you best practices for helping your patients remain adherent to their medication therapies and educate them on the role that statins play.
Prescription Drug Plan
We use drug lists, along with gaps-in-care messaging, to support overall member health. We look at how drugs work in the real lives of our members, then use our medical and pharmacy data and analyze claims analysis to make sure the medications really work.
But that’s just the beginning.
Improving the Health of Our Members
We encourage medications that improve patient health. We see how drugs work in our members’ real lives and help them make good health care choices.
Reducing Total Health Care Costs
Cost-of-care and clinical programs focus on total costs, and we encourage medications that help to reduce those total costs. Both medical and pharmacy costs are our responsibility.
Ensuring Coordination of Care
Medical and pharmacy strategies complement each other; they’re based on the same goals. Policies are aligned. We engage members and you, their doctors.
Simplifying the Member Experience
Our medical and pharmacy experts work collaboratively. Members have one vendor, one contact, and one ID card. Clients have one vendor, one contact, one contract, one eligibility feed, and one invoice.
Some drugs, and certain quantities of some drugs, require an approval before they are eligible for coverage. The Prior Authorization process allows for the request and approval of these medications.
Online Prior Authorization Requests
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Medical Prior Authorization requests can be submitted through CoverMyMeds.
Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Member and Physician Engagement
We drive compliance to improve health and reduce costs. By using targeted, concise communication, we help members make good health care choices and improve health outcomes. Members don’t receive multiple letters focused on individual clinical and cost-of-care programs. Gaps-in-care messaging for our clinical and cost-of-care programs is included in one communication. And to help ensure coordination of care and compliance, physicians also receive a consolidated communication with similar messages.
Medication Review
Once we identify a gap in care, the member receives a personalized Medication Review, which contains pharmacy messaging for our clinical and cost-of-care programs in one consolidated, health plan-branded, monthly member communication.
MyHealth Note
When clients have both our medical and pharmacy benefits, we can access members’ combined medical, pharmacy and lab data—plus member eligibility and benefit information—in order to create a holistic health care picture. This allows us to send generic and therapeutic equivalent messages with member-specific cost savings.
Controlled Substance Utilization Review
Our Patient Highlights communication is focused on controlled substance care opportunities, including the identification of members receiving multiple controlled substance medications, high-dose opioids or opioids from multiple providers and filled at multiple pharmacies, or combinations of controlled substances that may indicate risk.
Drug List Management
We are leading the health care industry in the way we choose covered drugs, analyzing the strongest clinical drug studies and member data to see how drugs are really working for patients. We believe the right drugs to cover are the ones that do the best job for our members and reduce the total cost of care.
What if a medication is not on the Drug List?
Our drug lists allow members and their doctors to choose from a wide variety of prescription drugs. Members should talk with their doctor about prescribing a drug that is on the drug list. If a medication is selected that is not on the drug list, the member will be responsible for the full cost of the drug.
