Government-Sponsored Plans

Trust our extensive experience with Medicare, Medicaid and Exchange

Government Sponsored Plans

Crafted End-to-End Solutions for Government-Sponsored Plans


Elixir serves some of the largest Medicare, Medicaid and commercial health plans, including our own Medicare Part D plan with nearly 1 million members nationwide. Our staff of healthcare and compliance experts have proven abilities to improve member health outcomes, quality scores and Star ratings—without losing focus on the member. With our vast knowledge and expertise, we have developed a mix of industry leading solutions to meet your needs.

Insight-driven Clinical Programs

Elixir provides the clinical programs you need to reduce unnecessary spend with a focus on improving member care. Our clinical programs are designed to detect and correct any gaps in care so members are provided the right drug at the right time and the right price. This is not just about the cost; it’s about how the medication is being used, if it should be used and what is best for each member. These programs range from standard offerings, such as step therapy, prior authorization and drug utilization reviews, to specialty programs uniquely crafted by Elixir to address industry issues from a clinical perspective.

Elixir’s specially trained nurses and pharmacists conduct interactive, personalized Comprehensive Medication Reviews (CMRs), which support a true impact on closing care gaps and increasing adherence. Our MTM-certified nurses and pharmacists, known as Care Navigators, contact each member directly for CMRs and adherence interventions. Members can receive advice on their medications, get their questions answered, discuss side effects and cost savings opportunities, and any other barriers to adhering to their medications.

Compliance and Medicare Expertise

Maintaining compliance for Medicare and Medicaid requires a strong pharmacy benefits partner with the ability to interpret and adhere to regulatory guidelines. Elixir serves more than 2.5 million Medicare beneficiaries, including our own independent, national Part D Plan. Our Government Programs and Compliance departments provide expert insight, direction and guidance for Medicare as well as accurate, quality checked standard processes that ensure compliance.

Elixir’s team of compliance professionals are subject matter experts in health law, pharmacy, CMS program audits, fraud prevention and audits/monitoring. With our broad scope of expertise, we can work collaboratively with you across several critical areas:

  • Compliance, certification and risk mitigation needs in connection with Medicare Part D requirements
  • Clinical operations
  • HIPAA privacy, security and security breach notification
  • Coverage determinations, appeals and grievances
  • Claims audits and special investigations
  • Pharmacy network credentialing
  • First-tier, downstream and related entities

Tailored Plan Designs

We understand that one size does not fit all. You might need different plan designs to meet your different member population needs. We have the willingness and ability to offer tailored options and the scale to provide proven solutions quickly—either our own in-house services or other resources. We use a consultative approach to understand your needs and the needs of your members to craft plan designs that are the right mix for you.

Balanced Formulary Strategy

Formularies are important tools for ensuring the selection of safe, effective and affordable medications for members while maintaining or improving the quality of care and limiting financial exposure. Our formulary strategy focuses on the health and safety of the member through the balance of clinical effectiveness, economic impact and member experience. We also understand the needs and regulations of the Medicare and Medicaid populations and design formularies accordingly.

Cost-Saving Pharmacy Network Options

Elixir has one of the industry’s largest CMS-compliant pharmacy networks, with over 64,000 pharmacies nationwide, including large retail chains, many local independent pharmacies, mail order and specialty pharmacy options. We also offer a variety of pharmacy network configurations that can increase savings and improve health outcomes for members without disruption:

  • Focused Network – After an analysis is conducted, it is often determined that the majority of pharmacies in a broad network are rarely utilized. By focusing a network and excluding one or more pharmacy chain options, members will still have a number of pharmacies in close proximity to their homes and, because pharmacies are generally willing to provide deeper discounts if they are part of a focused network, both the member and the plan will experience significant costs savings.

  • Preferred Network – A two-tier copay option where members are not restricted on which pharmacies they use; however, there is a lower out-of-pocket cost at preferred pharmacies. By increasing utilization at specified pharmacies, you can increase savings.

  • Performance Network – Pharmacies are rewarded for certain performance measures selected by the client, such as formulary compliance, generic dispensing, 30- to 90-day fills or based on disease state. This option can help drive behaviors that will ultimately improve costs and health outcomes.

Elixir’s expert staff works with plans to determine which network configuration provides the most savings with the least member disruption.

Dynamic Technology and Comprehensive Reporting

Elixir owns and operates its own technology and claims adjudication platform, giving us the ability to support diverse benefit designs and make changes quickly and efficiently. Providing superior performance and industry leading uptime, claims undergo hundreds of edits to achieve accurate processing results, regardless of the complexity of the plan design. Additionally, our Rx Business Intelligence Reporting Tool (RxBIRT) offers easy-to-understand data for better decision making. This web-based reporting tool gives clients access to a variety of reports with actionable data to help you make the best decisions for your plan.

An Enhanced Member and Client Experience

At Elixir, we help members improve whole-being health with balanced clinical options and convenient tools and resources to help members manage their pharmacy care, including 24 hours a day, seven days a week service—whether by phone, email or online.

Elixir assembles a team of experienced experts to assist clients on their journey to transform medication management. You will have direct access to a dedicated account team under the leadership of a knowledgeable clinical account executive, where care coordination and clinical oversight will be individually managed per your needs and requirements.