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Care Management

Care management programs we offer help address members who are:

  • Seriously ill or have complex conditions
  • Managing a chronic condition
  • At risk for developing serious or chronic illnesses
  • Recently hospitalized and could benefit from after care or transitions in care support
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How we identify members

We identify members based on multiple sources, including medical and pharmacy claims, and other self-reported information.

What we do

Interventions are designed to help members avoid illness, boost wellness, enhance quality outcomes, and decrease health care costs by addressing gaps in care and medication management in accordance with their clinician’s or physician’s treatment plan. These interventions may include:

  • Educational and informational materials to help members understand and manage their medications, make appropriate lifestyle choices, and find additional resources for support
  • Ways to plan for effective doctor visits
  • Preventive screening and lab reminders
  • Review of medications to address any potential safety issues, adherence, or other reminders
  • Reviewing social determinants of health, such as food insecurity and financial issues, and offering support to help address those needs
  • Case management and navigation support after a hospitalization

Some members receive additional nurse coaching by phone. We reach out to treating providers if there are specific concerns raised that you may need to be aware of.

How to make a referral

We welcome provider and member referrals. If you think a member could benefit from care management, please complete our Patient Referral for Health Management Programs & Services Form and return it to the fax number indicated. Or, call Health Management Programs at 1-800-392-0098, Option 1.

For questions about Federal Employee Program member referrals, please call 1-800-689-7219, Option 2.

For members with this plan Call
HMO, PPO, Indemnity Case Management
1-800-392-0098, Option 1
Federal Employee Program (FEP) FEP Case Management
1-800-689-7219, Option 2
Medicare Advantage Case Management
1-800-392-0098, Option 1
Medex Case Management
1-800-392-0098, Option 3

Other care solutions

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Mental health and substance use disorder

REACH (Recovery, Education, and Access to Community Health)
This program is offered at no cost to our members, through our partnership with Carelon Behavioral Health. REACH is designed to help patients with mental health difficulties and/or substance use disorder by arranging care with health care providers to ensure patients feel supported when they leave the hospital. Learn more about REACH.

Chronic conditions (Medicare Advantage)

Landmark Health
For our Medicare Advantage members with multiple chronic conditions, we offer Landmark Health. Landmark’s providers—physicians, nurse practitioners, and physician assistants—go to patients’ homes of patients to help keep them well, and provide urgent care when needed. This service does not replace the care provided by the member’s PCP.


Through claims data and other analytics, we navigate members to these care solutions that help complement the care they’re already receiving from their health care providers. Members can learn more on our Diabetes page or call us at the Member Service number listed on their ID card.

As always, members can find doctors, specialists, and durable medical equipment providers (for diabetic equipment and supplies) using our Find a Doctor & Estimate Costs tool.


  • Livongo is a diabetes management program that helps adults with type 1 or 2 diabetes to take control of their condition and treatment by introducing a connected blood glucose meter, personalized analytics, and access to coaching, including certified diabetes educators.
  • Available to self-insured accounts as an option.

Transform Diabetes Care

  • Transform Diabetes Care supports adults with type 1 or type 2 diabetes with glucose and blood pressure monitoring, preventive screenings, medication optimization and adherence, and lifestyle and nutrition management.
  • Support is offered through CVS Pharmacy, CVS MinuteClinic, and CVS HealthHUB locations, as well as remote options.
  • Available through our pharmacy benefit manager as a standard benefit to self-insured accounts who use our pharmacy benefits.
  •  Transform Diabetes Care member fact sheet

Virta Health

  • Through a mobile app and a clinical support team, Virta Health helps members reverse their type 2 diabetes without surgery and achieve full remission without medication. They offer nutrition therapy, physician-led care, education, and coaching.
  • Is available to qualified adult commercial HMO/POS and PPO members (does not apply to Federal Employee Program members). Eligible members need a smartphone to participate.

Cost Share Assistance with PillarRx
Offers members savings on high-cost specialty medications through drug manufacturer coupon programs. (Self-insured accounts with 100+ subscribers can opt-in to this product; Fully-insured employers can opt-in with 51+ subscribers; it is a core benefit on merged market plans).

Drug Savings Review
The program uses pharmacy claims to help deliver prescription drug savings and medication optimization through proactive provider outreach (Standard benefit for self-insured accounts).

Pharmacy Advisor
Uses pharmacy claims and social determinants of health data to identify members at risk for non-adherence. Pharmacists provide counseling to members on their medications. (Standard benefit for self-insured accounts).

Medical Cost Avoidance
Analyzes pharmacy and medical claims, plus other data to identify gaps in care. Program engages members in individualized interventions to remind them of the importance of preventive screenings, vaccines, and helps prevent hospital readmissions. (Standard benefit for self-insured accounts).

Medication therapy management (Medicare Advantage)

This medication therapy management program is offered as a service to eligible Medicare Advantage members. It’s offered through pharmacy benefit manager CVS Caremark and Outcomes Inc.

Chronic kidney disease

Square Knot Health, for select Medicare Advantage members

We are partnering with Square Knot Health, an independent company focused on patients with advanced chronic kidney disease (Stage 4, 5, and end-stage kidney disease). This program supplements the care that our Medicare Advantage members receive from their existing doctors by educating, assessing, and mentoring them as they consider treatment options, including transplantation.