Life Sciences

Account focus: Evercare clinical team has eye on coverage gap

Medicare & Reimbursement Advisor Weekly, August 26, 2009

by Bryan Cote

executive editor, custom research & publishing

I recently sat down to speak with Evercare’s clinical leadership team to hear about its greatest challenges and how account teams can help.

The organization serves more than 170,000 Medicare and Medicaid beneficiaries across the country through nursing homes, communities, end-stage renal disease programs, and hospice and chronic care improvement services. Here’s a sneak peek at our conversation. Note: The entire interview will run in a few weeks.


  • Mike Anderson, RPH, vice president of clinical services at United Healthcare (UHC) Health Alliance
  • Sally Brooks, MD, national medical director at Ovations and Evercare

How are your Medicare business lines structured?

There are about four million members in Evercare’s stand-alone PDP, which has only a pharmacy division. Its MA-PD, under the Secure Horizon’s division, has a more integrated model. As national medical director for Ovations, Brooks says each of Evercare’s market medical directors are very mission-oriented and focused on the most responsible way to educate providers and beneficiaries about safe and cost-effective use of the Medicare Part D benefit. The company uses a mix of open and closed formularies, with enhanced plans being more open. The Medicare Advantage plans have a separate formulary, based on their PacifiCare acquisition.


When asked whether Evercare has an across-business-lines subcommittee like Coventry does (see the February 27 MRAW), Anderson did not name one exactly like it. However, the organization has a committee feeding recommendations on formulary development—an Ovations pharmacy management committee that makes tiering decisions. The P&T committee meets quarterly and also in monthly intervals.

Medicare Part D

Formulary submissions are due to CMS in the spring and Evercare’s approach this time was program and benefit-design consistency and formulary stability. “Clinical trumps everything, but we have our eye on affordability and not making wholesale changes,” Anderson says.

Which classes are your focus this year?

Recent generic launches in the statin and osteoporosis classes have spurred Evercare and UHC to try to bolster beneficiary education about generics. Anderson notes that UHC has expanded its generics program this year to increase awareness about reasonable generic alternatives. A form is mailed to beneficiaries to bring to their doctors.

Beyond the contract

So what can account teams do to be successful with Evercare and UHC? “We’re a little unique in that we have Prescription Solutions in-house as our PBM, so the account folks must know the PBM contracting and clinical folks—the industry team here—since we stay on the same page on strategy all the time with them. We must collectively look at priorities. It’s most helpful when we work with account managers who understand the competitive pressures we face under Part D, how Part D plans compete in the market, and how that’s different from a commercial environment,” Anderson says.

What gets your attention?

“Account managers that look at things as a beneficiary would and understand how their drug interplays with the plan design have a leg up,” Anderson says. “If you make your case and fail to account for the fact your drug may put the beneficiary into the [Part D] coverage gap faster, then you’ve missed something critical to us.”

Special needs plans

Evercare is a leader in the special needs plans (SNP) area, with plans in almost every state (see enrollment analysis in April 9 MRAW).

“Our SNPs are not just pharmacy-based.We take a multidisciplinary-based approach. Pharmaceutical companies can help us with research or educational materials, caregiver tools,” says Brooks.

Brooks assists Evercare’s market medical directors in ensuring that members receive and use its multidisciplinary approach resources.


Evercare has been a pioneer in the long-term care (LTC) arena. It has a nursing home SNP with approximately 30,000 members, across more than 35 states, Brooks says. The formulary used for this population is the same as Evercare’s community program designed for dual eligibles.

Educational disconnect

There is often an educational disconnect among providers, family members, caregivers, and the plans, says Brooks.

“We need to figure out how to communicate with each other more effectively to enhance care, particularly for patients moving through the continuum; that’s a big challenge now, given how complex things have become,” she says.


“One challenge we have with the dual eligibles is that, in some cases, there is not the strong copay incentive for them, so it can be more difficult through our benefit designs alone to really get them to use generic options,” says Anderson.

Coverage gap

“Over time, there will be more opportunities, I think, for pharmaceutical companies to partner with us to help people who don’t qualify, for example, for the government subsidy, but are still experiencing financial hardship, still falling into the coverage gap,” Anderson says.