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Built-In Solutions

The following services are built into every RxCare Alliance Managed Plan.

Point-of-Sale Utilization Management
(Quantity Limits)

Establishes a maximum quantity allowed over a period of time for potential overused and misused medications.


Point-of-Sale Utilization Management
(Dose Optimization)

Identification, when appropriate, of higher-strength, single daily dose that replaces multiple daily doses.


Opioid Utilization Management Criteria

Enhanced opioid UM criteria are aligned with CDC Guideline recommendations to improve opioid use management and reduce chance of misuse. Stricter criteria uses Morphine Milligram Equivalent (MME) to limit opioid quantity.

Prior Authorization (PA) and Allied Advocate (AA)

Drug class management technique requiring select prescriptions meet defined criteria before they are covered.


Dispense As Written (DAW) Solutions

Mail DAW 1 and 2 is a mail intervention program that encourages replacing generic medication use for multi-source brand medication.


DAW Penalties

Cost penalty applies when non-generic brand medication is dispensed yet a generic equivalent is available.

Specialty Guideline Management

Evidence-based program before and during therapy that promotes safe and appropriate utilization of specialty drugs.

Point-of-Sale Safety Review

Flags potential medication safety concerns at point-of-sale.

Retrospective Safety Review

Reviews claims within 72 hours of adjudication to identify potential medication safety concerns.

Safety and Monitoring Solution

Safety and Monitoring Solution offers member claims analysis to determine risk of fraud, waste or abuse. Cases created by system generated risk scoring are presented to Clinical Pharmacists for manual review.

Unapproved Drugs

Excludes new-to-market unapproved products and existing unapproved products marketed contrary to the FD&C Act. Coverage remains for select unapproved products legally marketed or deemed clinically necessary.

Compound Drugs and Miscellaneous Formulations

Excludes bulk powders, costly compounding bases, hormone replacement therapy, compound kit ingredients, certain topical products including topical analgesics (ointments, creams and gels, etc.), patches, scar products, convenience, multi-product kits, otic analgesics and combinations.

Note: Antibiotics prescribed for patients receiving IV antibiotic therapy are most often covered since their exclusion would delay treatment.

Pharmacy Advisor® Support

Tailored messaging for members with chronic conditions at key points in therapy. Promotes optimal adherence, helps close medication therapy gaps, simplifies refills and renewals.

Note: RxCare PBM uses and shares data as allowed by applicable law, and by our agreements and our information firewall.

Care Management: Accordant Care TM Specialty

  • Proactive clinical model that focuses on whole patient care, including co-morbidity management.

  • Program for members who fill specialty medications through RxCare's PBM Specialty Pharmacy.

  • Accordant nurses work directly with Specialty Pharmacy Care team.

  • Condition-focused engagement helps identify gaps in member care and improve patient experience and outcomes.

  • Specialty conditions include multiple sclerosis, rheumatoid arthritis, Crohn’s disease, ulcerative colitis, hemophilia, cystic fibrosis, Gaucher disease, and systemic lupus erythematosus.


Diabetes Meter Program

  • Cost-savings program where the manufacturer provides an Accu-chek blood glucose meter at no cost to individuals currently using a meter other than Accu-chek.

  • Savings determined when purchasing blood glucose meter kits through program versus the retail price.

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