Evernorth Medical Drug Management

Evernorth Medical Drug Management delivers a robust suite of strategies for specialty medications within the medical benefit. Our tools maximize savings for plans, reduce gaps in care, enable cost-effective clinical decision making and minimize administrative demands for physicians.

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A doctor wearing a lab coat explains results to her colleagues

How are you leveraging pharmacy and medical drug expertise to address the impending tsunami of medical specialty drug costs?

The rise of complex, chronic conditions are driving up specialty drug use and costs to record numbers. This spend will only continue to increase over the next three years, with 200 specialty drugs set for approval. Fragmented, disconnected drug management strategies can lead to wasted time and resources, missed opportunities, and more work for health plans.

40% of specialty drug spend occurs on the medical benefit.1

As more drugs are administered in doctors’ offices, clinics or through home or hospital infusion, traditional specialty drug trend management tools must be leveraged on the medical benefit side to ensure patient safety and to eliminate waste.

With over 30 years of experience as a PBM, and over 25 years of Specialty Pharmacy (Accredo) experience, you can be assured our advanced clinical knowledge and organizational expertise will deliver a best-in-class review process that catches overspending that could otherwise easily be missed.

1. 2019 PBMI Specialty Drug Benefit Report

Woman paying for pharmacy products

Savings Guarantee

Evernorth's Medical Drug Management program offers clients a minimum savings guarantee, with an average client savings of $8 PMPM2.

2. Medical Drug Management BoB Data CY 2021

A man and woman sit together in front of a laptop to review a claim

Simply relying on prior authorizations alone can leave room for significant financial loss.

Before paying medical drug claims, many health plans ensure an approved prior authorization is present—however many systems end there.

The complexity behind specialty drug claims and the lack of system automation can often mean that the majority of medical drug claims are not checked for common errors including inappropriate billing codes, administration service codes, and drug waste.

Plans with utilization management in place but no payment integrity or dose management protection spend an estimated $5.99 PMPM more than plans that validate claims prior to payment.3

3. Medical Drug Management BoB Data CY 2021

Evernorth Medical Drug Management Can Help

Leveraging our industry-leading pharmacy and medical expertise to take on one of the largest cost drivers.

Over 400 medical drug policies ensure appropriate utilization and dosage

Prepayment review and claims edits to match against prior authorizations and validate clinical guidance

Site of care steerage to high-quality, low-cost settings

Complex home infusion drugs and services administered concurrently

Automated criteria with automated dose calculations reduce provider burden and turn-around time

Waste reduction through optimization

Visibility across benefits through OnePA, using integrated reporting and a single operational team to align benefit policies

Clock shows the time is 12:15

Enhanced determination reduces and eliminates time patients wait for treatment

Flexible Choices to Match Your Specific Needs

From software or delegated services, to claims management, or rebate support—Evernorth is flexible and here to support you.

Delegated support:

  • Policy development / maintenance
  • Medical necessity review
  • Dose management
  • Communications
  • Timeliness and compliance support


  • Medical policy license
  • OnePA software license

$3.55 PMPM savings4

(achieved through delegated services)

4. Medical Drug Management. BoB Data CY 2022


Delegated support:

  • Claims prepayment review
  • Medical drug claim edits
  • NOC code management
  • Waste management
  • Administration code management

$4.35 PMPM savings5

5. Medical Drug Management BoB Data CY 2022


Delegated support:

  • Advanced clinical evaluation
  • Home infusion therapy complete (HITc)
  • Oncology value-based pathways
  • Medical drug rebates

Savings Opportunities:

  • $5.35 PMPM HITc6
  • $1.27 PMPM rebate savings7

6. Medical Drug Management BoB CCUM data Q42021-Q12022; results may vary, dependent on prospective client savings analysis

7. MedRx Preferred rebate value, all lines of business, 2022

Leading the Industry in Managing Drug Trend

Our deep clinical knowledge drives powerful results and savings across both pharmacy and medical benefits.

PMPY projected savings for commercial plans8

8. 2020 Medical Drug Management BoB Data – QBR Savings Evaluation


Average savings for each site of care redirection9

9. 2019 Medical Drug Management Site of Care Program Performance – Client Quarterly Business Review


Minutes saved per case with automated self-service offering10

10. 2020 ESI Clinical Ops evaluation, examining OnePA system medical drug reviews compared to manual reviews of a clinician referencing clinical policy documents


Average savings from clinical protocols to ensure no waste and therapy appropriateness11

11. Medical Drug Management BoB Data CY 2022

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Let's Talk
Together, we can create a flexible, integrated strategy to help you stay ahead of medical drug costs and avoid waste.
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