Provider Central

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

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.

Here are some real-life stories of how our care management programs have helped our members.

Blue Cross member Jackie Brown

Support for Congestive Heart Failure “People with CHF need specific care and understanding of the disease. I got that at cardiac rehab and working with Claire and Nancy.” -Jackie Brown, Blue Cross member When Jackie Brown woke up in the hospital due to respiratory failure, she knew it was time for a change. The grandmother had been diagnosed with congestive heart failure—a serious condition in which the heart can’t pump blood efficiently, depriving the body of oxygen and other nutrients. With help from Blue Cross Blue Shield of Massachusetts’ registered nurse Claire Petrie and registered dietitian Nancy Dowling, Brown was able to make lifestyle changes to improve her health. Read more in Coverage: “A recipe for better health”

Blue Cross members Jim and Ann Bunyan

Helping navigate through a sudden, serious illness “Honestly, I don’t know how I would have gotten through this without her [Blue Cross nurse case manager Donna Buonopane-Johnson].” - Ann Bunyan, Blue Cross member During the hardest times, help can sometimes come from a simple phone call. Read the full story of the support the Bunyan family received.

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.

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.

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.

Livongo
An independent company that manages diabetes care for some of our members in self-insured accounts.

Transform Diabetes Care
Offered as a standard benefit to self-insured accounts through our pharmacy benefit manager, this is a high-touch, individualized experience for members with Type 1 and Type 2 diabetes. It includes monitoring, education, and access to diabetic screening and in-person visits at CVS MinuteClinic locations.

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).

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.

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.

Resources

• News article: New chronic kidney disease program for Medicare Advantage members
• Blue Cross Member Medicare Options
• Square Knot Health