Cost management
Solutions designed to deliver affordability and value include:
Innovative pharmacy solutions
CarelonRx pairs a strong, clinical-first lens with deep pharmacy expertise to create solutions that improve outcomes, control costs, and enhance each member’s health.
Prescription discount for non-covered drugs
Allows some medications that are not covered by the prescription insurance to be purchased at a discount.
Cost relief
Enable saving through a comprehensive member outreach program, coupled with key benefit design enhancements to specialty medications, for which we can help members get $0 copay assistance.
Specialty drug accumulator rules
Ensure that a plan’s cost share strategy operates as intended. We prevent non-needs-based manufacturer copay assistance funds from counting toward a member’s deductible and/or out-of-pocket maximum.
Whole person connected care
Solutions that harness insights from both the medical and pharmacy benefit, promote a digital-first member experience, improved outcomes, and lower costs.
Rx Care Nexus
Identifies potential gaps in pharmacy care related to adherence, appropriate use, medication compliance, safety, cost savings on generics and formulary alternatives for members who are identified as at-risk.
Specialty Condition Management
Focused on improving a member’s quality of life, specialty pharmacy nurses manage a holistic view of a member’s intervention history and offer advice on how to deal with specialty pharmacy therapies, their specialty condition, and any other conditions they may have.
Mandatory Home Delivery
Members must fill maintenance medications via CarelonRx Mail.
ZipDrug
Improved medication adherence with high-risk members, by connecting them to high-quality pharmacies that offer concierge services at no cost. These services include hand-delivery, coordinated refills, pre-sorted pill packaging and one-on-one counseling to help manage medications and health conditions.
Clinical insights
Products and solutions that promote the safe and effective use of medications, encourage adherence, and enhance pharmacy care.
Step Therapy
Requires a trial of an alternative drug that has evidence to show a greater clinical value or the same clinical value at a lesser overall cost.
Prior Authorization
Requires a clinical review to ensure there is evidence of effective and safe use.
Quantity Limits / Dose Optimization
Requires that the quantity and dose dispensed aligns with FDA guidance and promotes improved adherence.