Many specialty medications must be injected or infused. And many care settings are eager to perform the necessary task. However, costs can vary widely from one location to the next. Customers may think a hospital is the best place to have their medication administered. The reality is that hospitals often charge more than double that of equal service offered in a physician’s office setting, for example.1
Cigna's Specialty Care Options (SCO) team reviews each individual customer and specialty medication request, and then ties utilization management (UM) review with our site of care review. The first step is to evaluate the customer’s condition and needs, ensuring they get the right drug, in the right quantity and dose, for the right duration. The second step is to ensure they get the right site of care. This all takes place together as part of one initial review process, rather than retrospectively after treatment begins.
We determine the customer’s appropriate level of care and site of care to receive their medication(s). If the outpatient hospital setting is not medically necessary, we will help the customer identify and transition to an affordable, convenient alternate site of care to safely receive their treatment. If the customer requires an oncology treatment, we engage our SCO Plus process to determine site of care.
The ideal care setting is especially crucial for pricey meds, like oncology treatments
SCO Plus applies specifically to certain oncology treatments. SCO Plus is important because it takes into consideration that only some sites of care have the right personnel and resources to administer oncology treatments. By identifying opportunities at the point of prior authorization, SCO Plus can effectively redirect a customer to a safe, clinically appropriate and affordable site of care.
For higher-priced specialty medications, using the right care setting is all the more critical. Just for the drug Neulasta alone, we’ve achieved $39,000 in savings per case by redirecting to the ideal site of care.1 This drug is given the day after chemotherapy to help stimulate the growth of "healthy" white blood cells in the bone marrow. We added this drug to our site of care review efforts in September 2020.
Efforts by our SCO team have saved about $81,000 per successful intervention, per year.2
As of October 2021, we have over 130 drugs eligible for redirection as part of our SCO site of care steerage. Major savings can result when our SCO team redirects management of these high-touch specialty drugs to more appropriate care settings. An ideal site of care should be clinically appropriate, convenient for the customer to access, and cost-efficient.
“The most cost-effective option is often at a doctor’s office, freestanding ambulatory infusion center, or even a customer's home, supervised by a home health nurse,” explained Mark Johnson, clinical strategy product director for Cigna Pharmacy.
At the heart of SCO is a team of care professionals
These include medical directors, pharmacists, case manager nurses, and care associates. If a request comes in for approval of a specialty medication that requires a high-intensity care setting, for example, we will schedule a peer-to-peer conversation with the provider and a Cigna Medical Director to explore options that lead to the most clinically appropriate and affordable outcome for the customer.
Our SCO team helps to oversee a smooth transition to the preferred site. All the while, we continue to offer educational support and work to identify and close any gaps in care.
Our SCO team always remains respectful of each customer’s unique needs. We recognize that there may be situations where the outpatient hospital setting is medically necessary, due to the customer’s clinical condition. In such an instance, we would refrain from transitioning the site of care.
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