Eliminate Specialty Waste with Indication, Weight-Based Dosing

Preventing inappropriate dose escalations can help lower specialty costs

BRIEFING
April 13, 2021

Effectively controlling spending on high-cost specialty medications and saving payors money requires not only ensuring that the right patients start on the right treatments at the most appropriate time, but also eliminating waste throughout the course of therapy. In fact, the largest portion of specialty spend – 89 percent – is driven by ongoing therapy for plan members already on specialty treatments.

89% of specialty pharmacy spend is during ongoing therapy for existing users

As part of our dynamic approach to specialty cost management, we continually evaluate our solutions to ensure that we can help our clients drive more appropriate therapy, mitigate waste and lower overall costs.

There is an expanding prevalence of weight-based dosing for many specialty therapies. Because of this prevalence, a standard enhancement we’ve added to our utilization management (UM) strategies is member-specific dosing limits for new utilizers at the time of prior authorization (PA) beginning with autoimmune therapies (AI). Utilizing indication and weight-based dosing helps proactively and prospectively prevent inappropriate dose escalation and ultimately avoid wasteful spend by making sure therapies are being prescribed based on recommendations from the U.S. Food and Drug Administration (FDA).

Psoriasis case example for precise and sophisticated quantity 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.


Monitoring Analysis
 
Insight
 
Criteria & Process Updates
 

39%
of Stelara utilizers may exceed condition-specific FDA recommended dose

Extra level of control recommended

Checkmark FDA recommended dose for Stelara varies by indication and weight

Member-specific dosing limits

Checkmark Applied during PA
Checkmark Prospectively prevents inappropriate dose escalation and avoids wasteful spend

Monitoring Analysis

39%
of Stelara utilizers may exceed condition-specific FDA recommended dose

Insight

Extra level of control recommended

Checkmark FDA recommended dose for Stelara varies by indication and weight

Criteria & Process Updates

Member-specific dosing limits

Checkmark Applied during PA
Checkmark Prospectively prevents inappropriate dose escalation and avoids wasteful spend
Delivering up to 8.4 percentage point reduction
of high-dose Stelara use in psoriasis and psoriatic arthritis from member-specific indication and weight-based quantity limits
Want to learn how member-specific dosing limits and other enhanced UM strategies can help your plan save on specialty costs? Ask Us
BRIEFING
April 13, 2021

Data source, unless noted otherwise, CVS Health Enterprise Analytics, 2021.

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.

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