Plan support

Whether it’s 1 member or 1 million, at Magellan Rx Management we treat every Medicare client with the same ​commitment to your membership with intense dedication, attention to detail and boundless resources. We strive to provide transparent plan support to our clients and members of all shapes and sizes, ensuring smooth operations and satisfied members. Learn more below about some of our strategic support offerings for Medicare clients.

Network management

With 65,000 pharmacies in our network, we operate with a holistic approach to include a retail network of large chain pharmacies you know and trust as well as local and independent pharmacies, mail order, home infusion, long-term care and Indian Health Service/Tribal/Urban Indian Health Program (ITU) Pharmacies. We strive to create accessible options for every member, regardless of location and situation. All our network pharmacies go through a rigorous annual contracting and credentialing requirement process to guarantee superior quality and service standards are met.

In addition to a diverse pharmacy network, Magellan Rx Management offers strategic network management services to assist our clients with network expansion opportunities. Our network team works closely with our clients to create service expansion strategies in order to ensure CMS geoaccess requirements are met.

Benefit configuration

A smart benefit design is top-of-mind for established and start-up Medicare clients alike. We understand the importance of providing benefits that meet the needs of your population as well as meeting your strategic needs as a client. Our benefit consultation process ensures a close collaboration with you to ensure benefits are configured correctly and are representative of your requirements. Whether it’s creating a new plan from scratch or transitioning members from an existing plan to a new plan, we are here to help you provide a seamless process and eliminate member disruption.

From the start of implementation, we conduct extensive end-to-end benefit testing that incorporates client sign-off every step of the way to ensure full transparency during your benefit build. We enact a post-implementation benefit monitoring strategy as well to ensure eyes are on your benefit configuration well after it is up and running.

Coverage and organizational determinations, appeals and grievances (CDAG and ODAG)

Our Medicare CDAG and ODAG teams are comprised of dedicated and experienced Clinical Pharmacists and Certified Technicians, Medical Director, a Call Center and UM Support staff, a dedicated Post Adjudication (DMR/IRE) team and a dedicated Grievance team. This team works tirelessly to ensure that compliance and quality assurance are constantly addressed, ensuring client and member satisfaction.

Compliance is always top-of-mind with our team. Continuous daily monitoring of Medicare Part D queues takes place, ​ensuring compliance turnaround times are met. There is also a daily review of all Coverage and Organizational Determinations and Appeals to ensure we comply, and each request is correctly classified. Additionally, our Call Log Report is reviewed and completed retrospectively to determine if the member call needs to be triaged as a Grievance, Coverage Determination, or both.

Various quality assurance checks are in place to make sure our operations are serving our clients and members at the highest possible level of accuracy. Monthly, we perform a retrospective Denial Letter Review of at least 10% of all denial letters, a Quality Assurance Review of four cases per pharmacist per month (including clinical decisioning) and a Quality Assurance Review of four phone calls and four faxes per technician. Our team performs one hundred percent (100%) prospective claim review for DMR requests, as well as a quarterly case review by medical director and clinical staff to validate appropriate clinical decisioning and denial rationale.

Customer care center

Our Medicare Customer Care Center is fully staffed with helpful representatives 24 hours a day, 7 days a week to answer any questions your members have about their plan coverage. Our Customer Care Center team members are knowledgeable on all things Medicare and are provided targeted training on client-specific plan information and demographics as well. You can expect accurate, friendly and useful assistance when your members call us, day or night. Our goal is that every member who calls us leaves the call feeling satisfied and cared for.


We understand that the sheer number of statistics, trends and numbers related to Medicare plan membership can be overwhelming. At Magellan Rx Management we strive to simplify the information flow by providing concise, accurate, and illustrative reporting for our clients to easily understand what is happening with their membership. We provide a wide variety of reports to fully paint the big picture as well as the small details.

Some of our reporting capabilities include:

news | Magellan RxCreating CDA Daily Monitoring
and Call Log Reports

call | magellan rx managementConducting weekly PDE calls and provides
current error reports to clients on a weekly basis

fax | magellan rx managementProviding weekly summary of HPMS memos, key Medicare ​legislation, regulations and other CMS-issued guidance with client/plan takeaways and action items

Read | Magellan RxProviding the following monthly dashboard reports:  Medicare Correspondence Dashboard; Medicare Grievance Dashboard; Coverage Determination & Redetermination Dashboard; Member, Prescriber, and Pharmacy Help Desk Call Stats

Star Ratings/HEDIS

The CMS Star Rating program measures the experience Medicare beneficiaries have with their health plan. We see the Star Ratings program as an opportunity for continuous quality improvement and new opportunities for clinical programs and measures.

Our dedicated leadership consisting of doctors, pharmacists, and clinicians stay ahead of existing and upcoming quality measures to help our customers achieve and maintain 5 Stars and improve our members’ overall care. Magellan Rx ​achieves optimal Star/HEDIS performance by:

MRx Explore | Magellan Rx ManagementAdvanced Analytics: leveraging pharmacy and/or medical claims data to identify baseline and recurring outreach opportunities

Social distancing | Magellan Rx ManagementDynamic Platform: Our clinical team utilizes a ​proprietary platform to track all interventions and generate detailed reporting, including population and member-level metrics.

clinical committee | magellan rx managementClinical Outreach: All outreach to members, prescribers and pharmacies is conducted on behalf of the health plan/client utilizing plan-specific supporting documents and information that summarizes the program, recommendations and clinical guidelines.