Payer Solutions

Payer Solutions

As a payer, you’re at risk for the cost and quality of pharmacy utilization. How do you ensure high-quality, cost-effective therapy over large populations? There is no one-size-fits-all solution. That’s why CSS Health’s Payer Solutions are as varied and unique as your situation.

We have a Payer Solution for you, whether you are:

  • A Commercial Health Plan Business
  • An Organization that serves Medicaid or Medicare Part D patient populations
  • A Pharmacy Benefit Management organization looking for ways to add value for your customers
  • A Provider Group who has taken risk for pharmacy
  • A Self-Insured organization that wants to keep its valued employees healthy and its costs low

Medicare Part D

CSS Health’s Medicare Part D Solution is flexible, and audit hardened.

At the core of all of CSS Health’s Medication Management offerings is MTM PathTM, the pharmacist EHR. It’s designed for high volume, high quality, reliable drug regimen review. You can configure your Part D MTM program exactly to your CMS program submission.

The CSS Health Clinical Call Center can provide you with full-service CMR outreach or support your team on an as-needed basis. Regardless of which option you select, your MTM program will be supported with regular, weekly reports by one of our Account Management teams.

  • Top Box CMR Rates. CSS Health’s standard program forecasts your CMR needs and provides you with the insights needed for high-level CMR performance.
  • Audit Hardened. MTM Medicare Part D is an audit-tested program, with clients typically passing multiple CMS audits without issue.
  • Quality Add-Ins. Seamlessly add Adherence Improvement and other Quality Metric Improvement (SUPD, COA, etc.) programs to your MTM effort.
  • Program ROI. Calculate the direct cost savings or Total Cost of Care changes that result from your MTM efforts.


Medicaid populations are different than Medicare populations—so a Medicaid MTM program should be designed differently. With CSS Health and MTM PathTM, you have the ability to design your Medicaid program to suit your population’s needs. You can focus on a disease state (like behavioral health), a utilization problem (like adherence), or a therapeutic problem (like opioid overuse).

  • Drug Therapy Problems. Have your MTM team focus on the drug therapy problems that matter in a Medicaid population (e.g. opioids, children’s use of antipsychotics, etc.)
  • Deprescribing. Deprescribe complex regimens by eliminating legacy and inappropriate drug use.
  • HEDIS Quality Improvement. MTM PathTM comes complete with clinical rules to alert the clinician that a patient may not be addressing a particular HEDIS quality metric.

Commercial and Self-insured

Designed to help payer organizations reduce costs, improve quality of care, and promote wellness, CSS Health’s commercial and self-insured solutions will help you improve outcomes for both simple and complex disease states. MTM Solutions for Commercial and Self-Insured plans also address medication driven absenteeism, urgent care visits, and hospitalizations.

  • Inefficient Medication Use. Configure an MTM program that can address the use of High-Cost Generics and Non-Formulary medications.
  • Prior-Authorizations. Use your MTM program to follow up on prior authorized medications and ensure that they are delivering the clinical results that you and your patients are paying for.
  • Medical Pharmacy. A significant percent of your medical costs comes from drugs administered or infused in the outpatient setting. MTM PathTM combines both medical and pharmacy claims so you can address drug utilization regardless of where it occurs and easily identify therapy that is administered out-of-indication or in high-cost settings.

Pharmacy Benefit Managers

CSS Health and MTM PathTM provide a turnkey, white-label platform to provide your clients with MTM services. Design very simple DUR-like programs or very high-intensity (e.g., Diabetes Coaching) programs.

  • Cost Effective Solutions. Load all of your clients’ data into the MTM PathTM platform and it’ll be ready to go when your client is ready to engage your MTM solutions.
  • Hierarchical Platform Design. Have each client’s data segmented into its own environment.
  • Flexible Program Application. Start and stop MTM programs tailored to your client’s needs.

Provider Organization

More and more provider organizations, such as physician groups, are taking risk around the cost and quality of drug use. Typically, provider organizations struggle to coordinate their finite clinical pharmacy resources to identify and address the critical and high-volume drug therapy problems that persist in an at-risk patient population.

  • High-Volume, High-Quality Medication Regimen Review. The MTM PathTM platform was specifically designed to allow pharmacists to scale their caseloads. Increase the productivity and efficiency of your clinical pharmacy staff.
  • EHR Integration.  MTM PathTM can integrate with multiple EHRs using community-standard FHIR resources.
  • Clinical Call Center. CSS Health maintains a Buffalo, NY-based Clinical Call Center. If your organization has limited clinical pharmacy resources or your clinical pharmacists need support for a large patient outreach, CSS Health can help.