Pharmacy Management Programs

Coverage Management | Drug Surveillance
Pharmacy Surveillance | Compound Management | Pain Medication Management | Medical Drug Management | Specialty Drug Management | Advanced Adherence Program | Integrated Drug Utilization Review | Copay Adjustment Programs | Generic and Home Delivery Incentives | Formulary Options | Flexible Network Choices | Emerging Therapies

Coverage Management

Coverage Management previously consisted of establishing policies with broad strokes affecting thousands of people. With specialty drugs accounting for more than 50% of drug costs and only being used by less than 2% of patients, Medical Mutual’s clinical team takes a drug-by-drug view at current research to ensure our policies are the most precise, timely, and comprehensive in the industry and ensure members’ access to the right drug for the right condition at the right cost. The three components of our Coverage Management program are prior authorization, step therapy and quantity limits.

• Prior authorization rules are determined for specific drugs and/or drug classes and require a coverage review with the member’s physician before the prescription will be covered by the plan.
• Step therapy rules promote the use of lower-cost generics and preferred brand-name alternatives in place of more costly medications. This program targets a few high-cost medications in select classes offering both generic and highly discounted brand-name alternatives in the same therapeutic class.
• Quantity limits evaluate the quantity of a drug requested in conjunction with prior prescriptions submitted within a specific period.

Drug Surveillance

On a weekly basis, Medical Mutual’s clinical pharmacy team takes immediate action to control costs and maintain access to clinically effective alternative drugs by monitoring price changes and new drugs.

As part of this program, we protect our groups by blocking “me-too” drugs, or drugs with low or no therapeutic value and clinically appropriate alternatives. For example, Ortho DF is a combination pill containing folic acid and Vitamin D. These two ingredients can be purchased over the counter for less than $20 per month compared to $2,800 a month for Ortho DF. 

Pharmacy Surveillance

We periodically review claims from our network pharmacies to determine whether they have appropriate dispensing patterns pertaining to certain medications, particularly with high dollar topicals. If it is determined that a pharmacy is dispensing a disproportionate volume of these medications, then they are subject to removal from our pharmacy network. We also closely monitor out-of-state pharmacies with high dispensing volume to ensure that they are dispensing according to best practices. By monitoring these pharmacies closely and removing them from our network as warranted, members and groups are saving expenses that would have otherwise been incurred.

Compound Management

Our industry leading compound management program, started back in 2013, continues to evolve.  This program now excludes coverage for all compound claims containing non-FDA approved bulk powders, commercially available tablets, non-FDA approved kits and pain patches. When a compound is medically necessary for a member, we will coordinate with our clinical pharmacy team to ensure the pharmacy dispenses an appropriate compound.

As an example, we discovered that a member’s child was almost out of a compound medication but the pharmacy was reluctant to refill until the claim was paid. Our pharmacy liaison coordinated for ongoing early refills so that situation would not happen again.

Pain Medication Management

We are continuing to combat the opioid crisis with a unique, comprehensive program that emphasizes appropriate use, coordination of care and connecting members with helpful resources. As the government established additional laws and regulations aimed at curbing the opioid epidemic, Medical Mutual has furthered that effort by including a comprehensive corporate medical policy aimed at identifying our highest risk members as quickly as possible. We have been a leader in the industry in engaging members and providers to ensure appropriate use of opioid medications. Our program focuses on early education and prevention as well as getting needed treatment to members impacted by this crisis. We avoid the approach of simply blocking opioids from use as this can harm patients who legitimately need this treatment. Our program instead guides members to high quality, local treatment providers, which couple Medication Assisted Treatment (MAT) with psychosocial support. As a result, Medical Mutual is consistently able to achieve lower opioid costs, most recently 40% lower as compared to other health plans. 

Specialty Drug Solution

Members needing specialty medications are required to use our specialty pharmacy network for their pharmacy benefit drugs, which provide extensive patient counseling and care throughout their course of treatment. Each member is contacted by a pharmacist to discuss their medication, provide any necessary training on the unique administration of the medications and ensure refills are handled appropriately. Our Specialty Drug Solution improves member safety, closes gaps in care, eliminates waste and lowers costs through improved discounts.

Advanced Adherence Programs (available at additional cost for self-funded groups)

Our advanced pharmacy model focuses on closing the critical gaps in a member’s care by monitoring and improving adherence to essential medications and optimizing therapies and doses. This strategy helps minimize plan and member costs through emphasizing the use of generics and reducing waste.

Screen Rx, our prospective screening tool identifies members at risk of becoming non-adherent and offers them tailored, proactive interventions. This tool puts health decision science into action by applying actionable data, behavioral science and clinical specialization to improve health and financial outcomes.

Additionally, our interaction algorithm, RationalMed®, improves clinical quality through early risk detection and intervention by integrating medical, pharmacy, lab and member self-reported data. Through predictive modeling, we identify members whose prescription drug therapy may put them at risk for near-term hospitalization or other adverse events. Following an alert, 40% of providers make a change in treatment to address the gap or error identified. The net effect of these changes is significant savings in healthcare costs – savings that accrue from both a reduction in avoidable hospitalizations and from the more thoughtful and cost-effective use of prescription drugs. 

Integrated Drug Utilization Review (DUR)

This program improves outcomes by detecting safety and health issues from medical, lab and pharmacy data concurrently and retrospectively. By helping prevent adverse events while addressing gaps in essential care we help improve our members’ health and reduce costs.

• Concurrent DUR uses innovative information technology to proactively alert the dispensing pharmacist of potential drug conflicts online in real time. A proprietary clinical database checks all prescriptions to prevent members from experiencing inappropriate drug prescribing or consumption, medical conflicts or potentially dangerous interactions.
• Retrospective DUR concentrates on evaluating the entire member population for inappropriate utilization. Retrospective DUR identifies prescribing, dispensing and consumption patterns that do not meet established clinical practice guidelines. Physician interventions are then used to correct aberrant behaviors.
• High Utilization DUR is specifically designed to identify members who meet criteria indicative of excessive or abusive utilization. On a quarterly basis, our PBM partner’s clinical pharmacists review member profiles to target those medications that exhibit a high degree of abuse potential, identify those members that visit multiple physicians or pharmacies to obtain medications, and monitor utilization for excessive drug cost or excessive numbers of claims.

Copay Adjustment Programs

Medical Mutual offers multiple Copay Adjustment Programs that reduce costs for our groups and members.

• True Payment Processing - This program ensures that only the amount members truly pay for their specialty medications filled at contracted specialty pharmacies accumulates to their deductibles or maximum out of pocket amounts, preventing groups from overpaying on members’ claims.
• SaveOnSP - This program leverages manufacturer copay assistance to provide savings on certain specialty drugs filled at our contracted specialty pharmacies. The mechanics of this program include maximizing the manufacturer assistance available to provide savings to both our members and groups.
• Extended Payment Program - Allows members to spread payment out over time for long-term, maintenance medications when ordered through the mail. Groups benefit from the lower plan costs associated with members filling prescriptions by mail, and from members who are able to remain compliant with their medication regimen.

Generic and Home Delivery Incentives

Through these options, we incentivize members to use generic drugs when available and mail order for long-term prescriptions. Both of these options offer lower costs through improved discounts for groups.

Formulary Options

We offer groups both broad formularies, which provide members with more choices, or narrow formularies to take advantage of additional savings opportunities.

Flexible Network Choices

Groups have network choices, from broad networks to narrower options that improve discounts by excluding a major chain. We also have options for 90 days’ supply at retail as well as home delivery.

Medical Drug Management

Our advanced program extends beyond the traditional pharmacy benefit to encompass medically administered specialty drugs. The components of this program include an in-depth prior authorization process, advanced claim editing, concierge-level site-of-care and early intervention for high cost and high complexity members.

As an example of site-of-care, a member who needed Krystexxa infusions every 2 weeks to treat Tophaceous Gout had their treatment transferred from a hospital to freestanding facility. This resulted in annual savings of $1.9 million for the group.

Innovation for the Future

Medical Mutual recognizes that certain customers have select members who may not fit established criteria and require a more personalized approach. We created RxARMOR with these individuals in mind. Through RxARMOR, a team of dedicated clinical pharmacists looks for members with high-complexity or high-cost drug regimens and engages with them directly to improve their health. 

We identify members who may benefit from the program through advanced analytics that aggregate our medical and pharmacy data together. Once potential interventions are recognized, our pharmacists reach out to these members, their physicians, and their pharmacies to determine the appropriate course of action. This multi-disciplinary approach keeps the focus on the individual member involved and ensures their unique clinical profile is addressed in the best way possible. With RxARMOR, your members benefit from a concierge-level of support from our pharmacy team. This means better health for your members and lower overall costs.

Note: RxARMOR Is available at an additional cost for self-funded groups.