Medical Drug Management

For Better

The end to frustrating, fragmented
medical drug management is here.

Fragmentation exposes health plans to greater risk

Total drug management can be difficult to execute when measures aren’t taken to manage spend consistently across benefits. Drugs that are administered in doctor’s offices, clinics or through home infusion — a high percentage of which are specialty drugs — should be managed just as carefully as drugs covered under the pharmacy benefit.

The drug landscape is changing too rapidly for plans to get bogged down by fragmented drug management practices. Health plans need to implement a single, integrated strategy if they want to keep up and avoid waste.

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Some plans are duplicating work on 20% of claims in their highest specialty spend categories.

Almost 50% of those claims are being billed on both benefits.1

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In the past 4 years, specialty drug approvals have surpassed traditional approvals by around


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Projected medical drug spend in 2023 — a 33% increase from 2018’s $96B3

Fragmentation can create serious problems

Fragmented, disconnected drug management strategies can lead to wasted time and resources, missed opportunities and more work for Health Plans.

Click to explore some challenges of fragmentation.

Added Waste

Administrative challenges —
like billing, coding, and
documentation — lead to

$265 Billion
Annual Waste.4

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  • Fragmentation creates waste

    Drug spend accounts for as much as 23% of total health care spend1 and when it is not managed consistently through integrated datasets and workflows, there is potential for significant waste. A number of challenges prevent plans from achieving integrated drug management:

    • Claims system not connected to their UM system
    • Provider contracts that prevent medical UM entirely
    • Clinical or UM staffing limitations
    • Challenges maintaining clinical criteria for complex specialty drugs
    • Limited technology capabilities that don’t allow for sophisticated UM

    Some plans still have not implemented any kind of medical drug management solution at all.

Missed Opportunities

Plans haven’t always applied their
pharmacy drug management strategies
to their medically billed drugs.

This can be costly
and unsafe.

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  • Fragmentation creates missed opportunities

    Failing to apply a consistent, rigorous drug strategy to drugs billed under the medical benefit can be both costly and unsafe.

    • Approximately 20% of denied medical drug claims are outside of FDA dosing recommendations, and over 50% are duplicate claims1
    • Without UM and claim edits, clients may be paying for nearly a quarter of claims that should have been denied1

    Fragmentation increases the risk of duplicate claims and overpayment within and across benefits.

More Work

Keeping up with a changing
drug landscape is difficult.

Outdated systems
and resources
aren’t helping

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  • Fragmentation creates more work

    Multiple systems, manual file management — or no systems at all

    Many Health Plans use multiple systems or outdated processes, creating serious administrative challenges and wasting valuable time. A few still handle claims manually, physically moving files from one clinician’s desk to another. Some plans don’t manage medical drug spend at all, leaving them with serious cost, compliance and patient safety risks.

    Doing things the way they’ve always been done is no longer a sustainable option.

  • Keeping pace with the evolving drug market

    In order to keep up with the rapidly evolving drug marketplace, plans need greater clinical expertise, more rebate negotiating power, and advanced systems and resources — all integrated into a centralized cross-benefit platform.

    More high-cost drugs are coming to market, including biosimilars, gene and cell therapies.

    • The FDA expects to approve 10-20 gene therapies per year by 2025,1 with prices that may range from $850,000 – $5 million2
    • For the first two gene therapies on the market, over 95% of the claims we have filled have been covered under the medical benefit3

    Applying the right controls for medically billed drugs now is critically important.

It’s Time for Integrated
Medical Drug Management

Connected for Better

Optimize your drug savings across pharmacy and medical benefits

Our Medical Drug Management suite offers a full spectrum of drug management solutions designed to fit a wide variety of plan needs. And while the most value is driven by a cross-benefit strategy, we can implement these solutions as either standalone medical or a cross-benefit arrangement.

We have found that most of our clients are best served by selecting one of our two most popular approaches — either a full-service approach with dedicated medical support teams and a contractually guaranteed 3:1 ROI, or a streamlined, self-service software approach that puts you in the driver’s seat.


Better Efficiency

Save time with more effective utilization management (UM)


Better Savings

Drive increased value for your members and your plan

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Better Safety

Deliver improved outcomes and member safety

Both approaches seamlessly connect all your drug management processes. One data set. One workflow. One centralized set of experts guiding your strategy.

Our Approach incorporates decades of deep clinical knowledge that drive powerful results across both pharmacy and medical benefits.

30 years of pharmacy drug management experience

We lead the industry in managing pharmacy drug trend:

Under 3%

drug trend for plans three years in a row5


saved for plans by our specialty SafeGuardRx programs in 20186

20 years of medical drug management experience

We’ve delivered significant savings through our Comprehensive solution:


PMPY savings for commercial and $93.77 PMPY savings in Medicare lines of business respectively7

1 Out of 4

billed claims have required reconciliation actions by our program7


average savings for each case proactively redirected to a lower-cost site of care8

We’ve driven medical policy compliance and lasting behavior change
for prescribers, achieving a


66% Increase

in provider application of appropriate PA9


75% Decrease

in claims that exceeded the clinically recommended dosage9

Find the Medical Drug Management solution that is right for you

Answer these questions to see which recommended approach is better suited to your needs — or review our complete capabilities list and design a unique solution that is tailored to your specific goals.

Explore our Medical Drug Management solution suite Your suggested solution

Comprehensive Approach

A robust,


that reduces your clinical and administrative burden - with a guaranteed 3:1 ROI.

Core Approach

A streamlined, software-based,


that puts you in the driver’s seat.

Full Capabilities Index

Contact us to find a unique combination of flexible


tailored to your plan’s needs and savings goals.

If you'd like more information, please contact
[email protected]