Specialty Pharmacy

AultCare uniquely integrates local, expert pharmacy management with the external national strength of OptumRx Pharmacy Benefits Manager and two exclusive specialty pharmacies: OptumRx Specialty Pharmacy and Gentry Specialty Pharmacy. This integrated approach helps ensure members receive high-quality and optimal care while controlling costs when utilizing high-cost specialty drugs.

Identification

 Prior Authorizations identify potential high-risk claimants, promotes high-quality, appropriate treatments, and supports cost control.  Data mining from claims data.  Referrals throughout AultCare’s Care Coordination team.  Collaboration with specialty pharmacies.

Specialty Pharmacy

Process

 With the use of highly effective editing systems in place, high-cost specialty drugs require Prior Authorization or pertinent utilization management tools utilizing evidenced-based criteria. o Prior Authorizations are developed for immediate impact, but also to consider possible future impacts on medical costs.  AultCare’s Pharmacy and Therapeutics Committee reviews and approves Prior Authorization requests to ensure the proper drug and dosage are being utilized, and the appropriate site-of-care. o If approved, each case is re-evaluated at an appropriate frequency to ensure the efficacy of the treatment program.  While not only based on cost savings, the selection of a Specialty network helps provide clinical services, including member education, medication adherence, ability to recognize potential stockpiling preventing unnecessary dispensing, proper storage, and safe use.  AultCare educates members and providers on the potential cost savings for Generic Specialty Savings (GPS) by directing members to less costly pharmacies through the Prior Authorization process, if applicable.

Outcomes

The integrated AultCare program for high-cost specialty drugs monitors the following on an ongoing basis:  Quality o Adherence and overall effectiveness.  Safety o Monitored by a combination of the Prior Authorization process, system controls, and AultCare’s, in partnership with Optum’s Fraud, Waste and Abuse program.  Cost Control o Monitored through the Prior Authorization process aided by rebate optimization, and the contracting and network of administration for medications.

AultCare’s Commercial and Part D Pharmacy Team