Prior Authorization
A responsible review that requires approval before select medications or services are covered, so treatment is clinically appropriate and unnecessary or unsafe prescriptions are avoided.
Solutions
Clinical services for safe, cost-effective medication use.
Our clinical services combine proven utilization management with innovative technology so members get the most appropriate medications while costs stay under control and outcomes improve.
Talk to a clinical expert
What’s includedMaxCare clinical services are four core utilization management programs (Prior Authorization, Step Therapy, Quantity Limits and SmartBlock) plus eleven targeted clinical programs for specialty, GLP-1, biosimilar, rare disease and 340B spend. Together they deliver an average 25% savings on pharmacy spend.
Utilization management
Four core programs that work together
Step Therapy
Guides members through a cost-effective treatment path, starting with proven first-line options and moving to advanced therapies when medically necessary.
Quantity Limits
Sets clinically appropriate dispensing limits to prevent overuse, reduce waste and minimize risk, so members receive the right amount of medication.
SmartBlock
Excludes wasteful medications from the formulary, protecting the plan from high costs while keeping effective, lower-priced alternatives available.
How SmartBlock works$147,000
SmartBlock saved a current MaxCare client $147,000 on one drug for one patient in 2024.
Clinical programs
Eleven programs aimed at the fastest-growing spend
Contracts alone can’t control pharmacy cost. Our clinical team manages your highest-cost claims before they become budget problems.
Specialty Coupon Management
Capture manufacturer assistance programs to reduce member and plan cost.
High Dollar Exclusion
Redirect high-cost specialty claims to lower-cost alternatives.
Biosimilar Management
Accelerate biosimilar adoption with clinical and formulary guidance.
Proactive Utilization Management
Identify cost-driving patterns before claims compound.
Rare Disease Drug Management
Specialized oversight for ultra-high-cost rare condition therapies.
Site-of-Care Optimization
Move infusion therapies from hospital outpatient to lower-cost settings.
GLP-1 / Weight Loss Management
Clinical protocols for the fastest-growing category in pharmacy spend.
Concurrent & Retrospective DUR
Drug utilization review that catches problems in real time and over time.
Adherence Management
Improve member outcomes and reduce total plan cost through adherence support.
340B Program Access
Save 25–55% off AWP for eligible members through community-based 340B pharmacies.
Medical Rebate Management
Capture untapped rebates on 110+ injectable medications spanning 1,750 unique NDCs.
Why MaxCare clinical services
Clinical rigor without the runaround
- Protect member health through evidence-based controls
- Drive meaningful cost savings without sacrificing quality
- Streamline pharmacy workflows with real-time technology
- Stay ahead of evolving industry standards
- Support clear communication with members and providers
25%
average savings on pharmacy spend from our clinical programs alone
Watch
Clinical programs, explained
Clinical services FAQ
What clinical programs does MaxCare offer?
Eleven targeted programs: specialty coupon management, high-dollar exclusion, biosimilar management, proactive utilization management, rare disease drug management, site-of-care optimization, GLP-1 and weight loss management, concurrent and retrospective DUR, adherence management, 340B program access and medical rebate management.
What utilization management does MaxCare use?
Four core programs work together: Prior Authorization, Step Therapy, Quantity Limits and SmartBlock. They make sure members get clinically appropriate medication while the plan avoids unnecessary cost.
How much do MaxCare’s clinical programs save?
MaxCare’s clinical programs alone deliver an average 25% savings on pharmacy spend. In one 2024 case, SmartBlock saved a MaxCare client $147,000 on one drug for one patient.
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