Clinical Programs

Comprehensive Formulary Management

MedMetrics provides comprehensive, evidence-based clinical monograph materials for Pharmacy and Therapeutics (P&T) Committees that deliver objective, critical appraisals of new drug products.  We also provide well-designed comparative analyses of drugs within existing drug classes, based upon up-to-date clinical peer-reviewed data, national/ international consensus guidelines/recommendations, systematic reviews of the scientific literature, and access to input from key researchers and specialist consultants.

As complex drug therapies continue to hit the market and other factors drive greater utilization of these newer therapies, formulary decisions are more important than ever. Through our unique medical school affiliation and 100 percent transparent client relationships, MedMetrics brings the highest standard of clinical evidence and objectivity to formulary selection processes within the P&T Committees and state DUR boards that we support.

Our P&T materials (including industry-leading drug monograph, support materials and full drug-class reviews) set new standards for high-quality, unbiased, evidence-based analyses. The academic rigor in these documents and the integrity behind them help create enormous efficiencies for our clients’ pharmacy personnel, freeing them up to concentrate on higher-value administrative and operational priorities.

Unlike our competitors, MedMetrics is not hesitant to provide our clients with succinct, unbiased formulary positioning recommendations for new and existing drug therapies that clearly highlight potential advantages and disadvantages with each product. Our conclusions and recommendations are based entirely on the clinical merits of each drug product. We base our analyses on the latest evidence-based, peer-reviewed literature and customized reviews and evaluations of current utilization patterns, formulary alternatives, and relevant pharmacoeconomic factors.

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Multifaceted Generic Maximization Programs and Services

Unimpeded by ties to pharmaceutical manufacturers or a reliance on branded drug rebates as a primary revenue source, MedMetrics delivers to clients a unique approach to generic drug maximization that has helped achieve extremely impressive results.

Today, the average cost differential between brand and generic products is more than $120 per prescription. With a wealth of high-quality, high-value generic and OTC drug options across virtually all major therapeutic drug categories, strategies to optimize generic utilization are a cornerstone for adequately controlling continually rising drug expenditures without negatively impacting quality of patient care. MedMetrics can help you achieve exceptionally high generic utilization rates (>70 percent) without major provider/member disruption and without sacrificing quality of care.

In addition, MedMetrics offers clients unique and effective strategies to encourage the use of over-the counter treatments that can mitigate costs in several key therapeutic categories.

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Step Therapy

Step therapy enhances the use of safe, equally effective, and less expensive drugs before "stepping up" to more expensive alternatives. MedMetrics offers a multi-pronged approach to accomplishing this goal.

First, we design evidence-based protocols using only the latest and most sound medical evidence. We manage these protocols using state-of-the-art claims processing technology to screen a member’s prescription history and determine if that member has previously used a first-step drug before coverage is provided for a second-step agent. We provide electronic messaging to the retail pharmacy to help them understand coverage limits or exceptions that require contacting the prescribing physician. Finally, we educate and communicate all of our step therapy guidelines to physicians, pharmacists, and members through a variety of educational resources.

Through the combined power of our sophisticated claims processing systems and depth of our clinical resources, MedMetrics leads the way in step therapy technology. We offer step therapy protocols in more than 25 different therapeutic areas and have created innovative implementation tools and tracking mechanisms to help clients capitalize on their unique value.

Prior Authorization

Certain drugs with a high propensity for inappropriate use, safety risks, and/or excessively high costs are often better managed through prior authorization, where the physician requests a review and approval before the patient receives the drug. Recognizing that prior authorization is an interruption that frustrates physicians and members, MedMetrics is quite selective in targeting agents for prior authorization. We also have developed innovative prior-authorization management programs (e.g. use of Web-based applications) to increase efficiency and reduce administrative burdens for providers and patients.

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Dose Optimization

In many instances, prescription costs vary dramatically depending on the total daily dose and directions for use. For instance, a doctor might prescribe one daily 10mg tablet of a cholesterol-lowering drug. Later, he/she increases the total daily dose to 20mg, instructing the patient to take two 10mg tablets once a day. In this example, if the 10mg and 20mg tablets are both priced at the same level (e.g., $3.00 per tablet), then taking two 10mg tablets ends up costing twice as much, an added cost to the payer of greater than $1,000 per patient per year.

At MedMetrics, we are keenly aware of all therapeutic categories where this type of wasteful dosing may occur and have developed very effective solutions to mitigate cost exposures to our clients. By closely monitoring claims data, we can identify opportunities for dose consolidation and work with prescribers to convert patients to more efficient regimens. We also work closely with our clients to employ dispensing limits that can prevent inappropriate dosing.

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Specialty Drug Use Management

Specialty drugs are typically injectable, biotechnology-based, or expensive treatments for a wide variety of medical conditions. Since these agents represent a rapidly increasing proportion of total drug expenditures, effective control of their use is of paramount importance for successful pharmacy benefits management.

MedMetrics recognizes and embraces these challenges through a multi-dimensional strategy for managing these drugs which is primarily focused on, but not limited to, the following areas:

Unlike other PBMs, MedMetrics does not own or operate its own specialty pharmacy distribution facilities. That removes any incentives to drive unnecessary use of high-cost specialty therapies that generate added revenue for the PBM. Instead, we work closely with key specialty vendors to ensure only the most optimal distribution and use of these agents.

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Disease Management

Our disease management programs focus on improving member health and controlling client expenditures across the entire spectrum of healthcare services. MedMetrics programs address disease prevention, education, treatment, and long-term management of high-prevalence, chronic diseases including asthma, arthritis, osteoporosis, allergic rhinitis, hypertension, cholesterol management, depression, diabetes, and ulcer disease. The programs employ a variety of approaches, such as risk assessment, wellness and prevention education, drug utilization evaluation, clinical interventions, and outcomes assessment, and can be tailored to bolster your existing initiatives.

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Medication Therapy Management

MedMetrics offers a medication therapy management program that meets the objectives set forth by APhA and NACDS, and CMS for Medicare Part D compliance, encompassing medication therapy reviews, personal medication records, medication action plans, intervention and referrals, documentation and follow-up.

In consultation with our clients, MedMetrics identifies patients most likely to benefit from MTM programs, including those receiving medications from more than one prescriber, patients taking multiple chronic medications, therapeutic duplication, patients suffering from multiple co-morbidities, and/or patients demonstrating high levels of non-compliance.

As part of these MTM services, we evaluate several key criteria including:

Through these screening criteria, we perform timely reviews and monitoring and deliver comprehensive feedback.

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Retrospective Drug Utilization Review

MedMetrics uses its extensive clinical experience and expertise to analyze retrospective pharmacy claims history (and medical claims history where available) at the individual patient or prescriber level to identify patterns of care that may warrant clinical intervention. Known as retrospective drug utilization review (RetroDUR), these programs identify prescribing, dispensing, and consumption patterns that may be clinically and therapeutically inappropriate based on established clinical guidelines and/or best-practice standards. A variety of interventions are then employed to correct these situations.

At the heart of MedMetrics’ RetroDUR programming is a clinically robust, state-of-the-art DUR system. MedMetrics’ retrospective DUR program uses a multi-level approach to identify, filter, and communicate important information about prescribing and/or consumption patterns. We then conduct extensive follow-up analyses to measure the impact of these interventions.

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E-Prescribing

MedMetrics is on the front line of electronic prescribing initiatives that will soon become the standard of practice and care for drug program management. E-prescribing can provide numerous safety and cost-savings benefits to members and payers alike, and can yield substantial administrative efficiency for providers, pharmacies, and health plans.

MedMetrics works with RxHub®, the nation’s largest patient-health information network, to make individual patient prescription drug history and eligibility data readily available to providers at the point of prescription generation. We also support the maintenance of formulary information and drug-coverage protocols through a variety of e-prescribing platforms.

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