Better Managing Psoriasis Across the Duration of Therapy

Precision and continuous refinement

Continuous evaluation of solutions ensures that we can help our clients manage costs while ensuring clinically appropriate coverage of specialty medications. Our Enhanced SGM solution provides clients with greater choice and flexibility to have more stringent prior authorization (PA) criteria including additional documentation requirements to address utilization for certain complex therapeutic categories:

• Requires prior use of non-specialty drugs
• Limits coverage to select diagnoses and reduces approval duration
• Promotes less costly, therapeutically equivalent therapies

These strategies result in increased appropriate and durable denials. For all AI biologics, we're bringing more precision to cost management with techniques like efficacy assessment for renewal and indication- and weight-based dosing limits.

Case Study

Stelara is indicated for multiple conditions—plaque psoriasis, psoriatic arthritis, Crohn's disease and ulcerative colitis. Stelara dose should be determined using indication and weight.

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Monitoring Analysis	Insight	Criteria & Process Updates
30% of Stelara utilizers may exceed condition-specific FDA recommended doseCVS Health Enterprise Analytics, 2021. Stelara utilizers defined as any commercial member with paid claims for Stelara between Jan-Dec, 2020 and with an ICD 10 code, body weight data and minimum exposure threshold. Utilizers must have met the minimum exposure threshold to be considered in excess of FDA recommended dose: https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/761044lbl.pdf. All data sharing complies with applicable law, our information firewall and any applicable contractual limitations. Actual results may vary depending on benefit plan design, member demographics, programs implemented by the plan and other factors	Extra level of control recommended FDA recommended dose for Stelara varies by indication and weight	Member-specific dosing limits Applied during PA Prospectively prevents inappropriate dose escalation and avoids wasteful spend

	Monitoring Analysis 30% of Stelara utilizers may exceed condition-specific FDA recommended dose3
	Insight Extra level of control recommended FDA recommended dose for Stelara varies by indication and weight
	Criteria & Process Updates Member-specific dosing limits Applied during PA Prospectively prevents inappropriate dose escalation and avoids wasteful spend

Delivering up to 8.4 percentage point reduction of high-dose Stelara use for a gross cost savings of approximately $21M by updating our process to apply member-specific indication and weight-based dosing limits during PA.4CVS Health Enterprise Analytics, BOB Commercial Clients 1/1/2020 - 1/31/2021, March 2021. Savings projections are based on CVS Caremark data. Actual results may vary depending on benefit plan design, member demographics, programs implemented by the plan and other factors.

We also monitor supply on hand. While standard quantity limits manage quantity for a single fill, CVS Health is able to help manage the patient’s supply on hand throughout the year to reduce waste.CVS Specialty pharmacy patients only. Supply Management Optimization triggers personalized interventions during the refill process to help encourage patient behavior without requiring a benefit change. Artificial intelligence helps more efficiently manage drug therapy using a one-year lookback of dispensing data versus the month-to-month industry standard. The patient is contacted in their preferred channel, digitally or telephonically, and provided a preferred refill date to help avoid excess supply on hand.

Clients saved about $1,000 per targeted psoriasis specialty utilizerCVS Health Analytics, 2021. Data from Q1-Q2 2021. SMO psoriasis interventions, September 2021. SMO referenced savings are specific to Psoriasis. Actual results may vary depending on benefit plan design, member demographics, programs implemented by the plan and other factors. *Targeted patients make up <2% of all specialty patients.

Changing the treatment landscape with innovation

There are many novel approaches to help members manage pre-biologic therapies and remain on effective, lower-cost therapies. Forty million people in the U.S. suffer from psoriasis, vitiligo or eczema and have insufficient treatment options for phototherapy. UVB rays are present in natural sunlight. They penetrate the skin and slow the growth of affected skin cells. UVB phototherapy is an effective treatment for psoriasis and can be an economical and convenient choice.https://www.psoriasis.org/phototherapy/

Average three-year treatment cost of home phototherapy: $5,0008https://www.pharmacytimes.com/view/psoriasis-treatment-cost-comparison-biologics-versus-home-phototherapy

Given the clinical and cost benefit of UVB treatment, we have included it as one of the necessary prerequisite therapies in our psoriasis clinical policies and criteria. We are working on expanded approaches for using UVB phototherapy for better care and cost management.

A new pilot launched in October 2021 offers UVB phototherapy treatment via an app-controlled, connected UVB device that members can use at home. High-touch services support adherence and the member experience. Currently we have five clients participating in the pilot; we will continue to assess and consider options for the best next steps based on our learnings.

At CVS Health, we continue to invest, test, learn and identify new ways to create and exceed the results our clients expect – aggressively managing specialty costs while driving better health outcomes and experience.