Medicare

We help Medicare payors address growing cost pressures while providing high quality solutions, ensuring compliance, and supporting business growth.

CVS Health Client Growth Outpacing the Market: CMS-Reported Total Market Growth 2013-2016 was 4.8%. Growth of Plans Administered by CVS Health was 7.6% in the same period.

CVS Health has been a leader in Medicare Part D program management since its inception in 2006. We provide Part D services to approximately 12.5 million beneficiaries through a range of Medicare Advantage and stand-alone Part D plans. 

Our significant ongoing investment in our core operations and resources has helped clients achieve tremendous success and growth in this highly complex and regulated market.

CVS Health Client Growth Outpacing the Market: CMS-Reported Total Market Growth 2013-2016 was 4.8%. Growth of Plans Administered by CVS Health was 7.6% in the same period.

Cost and Quality Management

CVS Health has a broad set of capabilities to manage non-specialty and specialty spend, and help improve patient outcomes. Our solutions are tailored to meet each client’s unique goals, including a variety of formulary and pharmacy network options that provide flexibility and cost savings. Our Medicare-focused utilization management criteria help ensure appropriate medication use while our adherence programs and member engagement expertise support Star rating improvement.

Client Success:

$156,000
saved by a small health plan with our Medication Therapy Management program.
$1,300 PMPY
saved by large health plan from fewer hospital admissions with our Pharmacy Advisor Counseling solution.
$12.1 million
in savings for a regional health plan from our Drug Savings Review program.
  • $156,000 saved by a small health plan with our Medication Therapy Management program.
  • $1,300 PMPY saved by a large health plan from fewer hospital admissions with our Pharmacy Advisor Counseling solution.
  • $12.1 million in savings for a regional health plan from our Drug Savings Review program.

Star Strategy for Optimal Plan Quality

The Centers for Medicare and Medicaid Services (CMS) publishes Star ratings each year to measure plan performance and the quality of care provided to beneficiaries.

83% of Medicare Health Plan lives supported by CVS Health's pharmacy benefit manager are in high-performing - 4 or 5 Star - plans.

The dedicated CVS Health Medicare Stars Consultative Services team leverages a data-driven approach to identify improvement opportunities and provide recommendations on the right mix of solutions to augment performance across Part D and Part C* Star measures. They also provide educational support through webinars and industry best practices.

Best Practice Approach to Audit Support

Our investments in core audit processes and our audit team help support clients through changing CMS requirements, or in case of an audit. Our audit teams handle more than 300 Medicare audits each year, and that number continues to grow. 

We continue to produce industry-leading audit results in Formulary Administration (FA) and Coverage Determinations, Appeals & Grievances (CDAG) and actively share learnings from CMS interactions with clients.

Actuarial Consultation and Decision Support

CVS Health provides a comprehensive suite of actuarial support capabilities and relevant, timely, and actionable information to help facilitate the complex decisions government payors face annually.

At the annual Actuarial Client Forum, payors can learn how to leverage our pharmacy care solutions to help attain plan goals. A bi-annual Medicare Client Forum offers insights into actuary-related topics such as a competitive landscape overview, trend forecasting, formulary analysis, bid preparation, and Star ratings. The Bid Advisor reporting package provides program support with a team of experienced Medicare actuaries and pharmacists.

Consultative Support and CMS Engagement

Our teams help inform a client’s long-term strategic growth plan, including program prioritization techniques based on ROI experience and analysis. Our teams also keep a close eye on policy reform and changing government regulations, and engage with CMS on an ongoing basis to discuss trends and potential program enhancements. We also perform a detailed review of all emerging regulations and proactively communicate with clients to help assess the impact on their plan. 

As new guidance is released, the Regulatory Affairs group partners with clients to implement compliant solutions.

Considerations for your business
  • Do you have the right cost management strategies in place to ensure a comprehensive, sustainable Medicare benefit?

  • Is your plan on track to maintain or improve quality measure performance?

  • Are you getting the right level of support and guidance from your current PBM?

How can CVS Health help support your Medicare Part D business?

1. Source: http://www.foxbusiness.com/markets/2017/04/20/10-jaw-dropping-stats-abou...
2. Source: http://www.kff.org/medicare/issue-brief/10-essential-facts-about-medicar...

* Medicare Advantage plans

Unless otherwise noted, all data is from CVS Health Enterprise Analytics.