Clinical support

Magellan Rx Management’s approach and philosophy surrounding our clinical offerings is one key factor that helps sets us apart and makes us different from other pharmacy benefit management companies in the industry. We develop comprehensive clinical solutions that are data-driven, member and provider-centric, and cost-effective.

Our programs address gaps in care, deliver high-quality outcomes, and push boundaries and the industry forward – all while leading humanity to healthy, vibrant lives. We work to integrate all aspects of a member’s experience and pull their fragmented healthcare journey into an aligned healthcare experience. We pull together the gaps between Behavioral Health, Customer Experience, Physical Health, Clinical Quality, Health Information, and Reporting/Analytics to offer a comprehensive view of the member’s story.  This whole rounded view provides the opportunity to offer total care and integrate the care management between the pharmacy and medical benefits.

A sampling of the services most utilized by our Medicare clients are highlighted below

Formulary management

Magellan Rx Management works closely with CMS to ensure that we are offering a fully approved formulary, while also still offering customization and different options so our clients can choose the coverage that works best for their membership. We work with you to identify the most clinically appropriate and cost-effective products in each therapeutic class.

We use a web-based formulary management tool that manages the documents using a single source for formulary data, offers real-time adjudication updates, generates and maintains drug lookup tools for our client websites, creates and compares formulary reports, and generates published PDF ready prescription drug lists.

Our formulary documents include:

  • Protected Class
  • PAs, STs, and QLs
  • Monthly updates for newly released drugs
  • Files for CMS and beneficiaries are delivered in the required format for HPMS submission
Pharmacy & therapeutics (P&T Committee)

Magellan Rx Management incorporates 3 separate committees to make up our MRx National P&T committee which makes formulary development decisions based on best practices is the PBM and health plan industry. Our P&T committee is made up of:

  • Therapeutic Assessment Committee
  • Pharmacy and Therapeutics Committee
  • Value Assessment Committee

Our best-in-class practices have earned us accreditations with both URAC and NCQA for Pharmacy Benefit Management, Specialty Pharmacy, and Utilization Management.

Medication therapy management (MTM)

Ensuring appropriate and optimal medication use is a way we are helping patients live healthy lives and make better healthcare decisions. Our Medication Therapy Management (MTM) enables patients, and their healthcare providers to find the right medications to safely and effectively improve outcomes. Magellan Rx Management follows all guidelines and requirements mandated CMS to administer our MTM program. Our highly focused, individualized patient care program optimizes medication use, improves quality of care and reduces overall costs for clients and patients.

Opioid management

We recognize that opioids are commonly prescribed to Medicare members suffering from chronic pain and physical illness and we are committed to patient safety and awareness regarding these types of medications. Our Drug Management Program (DMP) helps make sure members safely use high-risk medications such as prescription opioids and benzodiazepines. To help minimize misuse or abuse of opioid medications, this program regulates how much opioid medication a member can receive.

Limitations may include:

  • Requiring a member to get all prescriptions for opioid or benzodiazepine medications from a certain pharmacy(ies)
  • Requiring a member to get all prescriptions for opioid or benzodiazepine medications from a certain doctor(s)
  • Limiting the amount of covered opioid or benzodiazepine medications

Safety is our main concern— our program allows us to ensure that members receive an appropriate amount of opioid medication while effectively treating medical conditions.

Utilization management

Our utilization management program provides a comprehensive clinically driven solution that promotes the safe appropriate and cost-effective use of medications.

  • Prior authorization helps ensure appropriate prescribing and member use
  • Step Therapy helps members and physicians consider lower-cost agents before more expensive ones
  • Quantity Level Limits ensure safety as well as preventing fraud, waste, and abuse
  •  Exceptions
  • Tiering exceptions
  • Formulary exceptions
  • Step Therapy exceptions
  • Prior authorization exceptions
  • Quantity limit exceptions
Retrospective drug utilization review (rDUR)

Clinical programs that optimize medication use and improve adherence can positively impact the overall quality of care. We are constantly evaluating clinical opportunities across various disease states to improve evidence-based treatment, drive clinical outcomes, and reduce unnecessary costs. Some areas we implement rDUR reviews are:

  • Statins in Diabetes/Cardiovascular Disease
  • High-Risk Opioid Use
  • Adherence
  • And many more!