Specialty Management

Putting the brakes on specialty spend.

By 2023, spend on specialty pharmaceuticals will total approximately $311B.CVS Analysis based on Evaluate Pharma, Market Research. U.S. specialty pharmaceutical market size including medical and pharmacy. June 2019 As the fastest growing area of pharmacy spend, effectively managing specialty treatments is the biggest pain point for payors and their members, and many are looking for ways to aggressively control costs. 

In 2020 alone, the U.S. Food and Drug Administration approved 34 new specialty treatments – 64 percent of all approvals – and 81 supplemental indications spanning 33 conditions.

More specialty treatments are being developed and coming to market for conditions previously treated with traditional therapies, those that had no treatments available, and expanding options to treat various conditions such as autoimmune conditions, and cancer.

Specialty is the biggest cost management challenge for payors today

~50%
of overall pharmacy cost driven by 2.5% of members using specialty medication
11%
of cost is incurred when therapy begins
89%
of cost is driven by members after the first fill
~50%
of overall pharmacy cost driven by 2.5%
of members using specialty medication
11%
of cost is incurred when therapy begins
89%
of cost is driven by members after the first fill

An integrated, laser-focused management approach is critical to help ensure low net cost and appropriate utilization. These conditions are also complex, making patient support and clinical engagement an important component of improving outcomes and managing spend by making sure the right therapies are being used at the right time for the right member.

Specialty cost management

The rapid growth of specialty spend requires an active and innovative approach. This includes increasing market competition to deliver lowest net cost and drive appropriate utilization with our industry-leading management criteria based on robust clinical guidelines.

There are a wide range of specialty management solutions available, and new ones coming to market, with the promise to help employers mitigate rising specialty pharmacy costs and protect their bottom line by controlling new utilization. Few however provide the clarity that proves the promised savings through claims data and actual results that can be compared for evaluation.

A small percentage of members utilizing specialty medications represent a disproportionate and growing share of pharmacy spend. So, it is vital that any management approach address costs from the beginning – when members are first prescribed a specialty therapy – and every step of the way over the duration of therapy.

We bring our integrated resources, including our reach, experience and expertise to help payors manage this complex, expensive area with a comprehensive approach that contains cost at every step of the process.

Detailed, transparent reports including prospective modeling and retrospective data analysis enables payors to clearly see how our strategies deliver savings for their plan.

Our integrated strategies help ensure that:

Checkmark Members start therapy with certainty
Checkmark We eliminate waste during treatment
Checkmark We intervene when needed

We bring our integrated resources, including our reach, experience and expertise to help payors manage this complex, expensive area with a comprehensive approach that contains cost at every step of the process. Detailed, transparent reports including prospective modeling and retrospective data analysis enables payors to clearly see how our strategies deliver savings for their plan.

Our integrated strategies help ensure that:

Checkmark Members start therapy with certainty
Checkmark We eliminate waste during treatment
Checkmark We intervene when needed

These strategies complement each other and help us deliver the most savings on specialty spend.

Medical benefit solutions

Drug spend under the medical benefit comprises nearly half of specialty spend for payors. Our integrated model applies the precision of pharmacy benefit management to complex and high-cost spend under medical, delivering more transparency and positively impacting clinical and financial outcomes. The automated cross-benefit platform, Novologix, enables a variety of strategies at the point of prescribing, featuring integrated prior authorization and medical claims management, site-of-care optimization and medical preferred drug strategies targeting high-cost drug classes, including oncology.

Patient care

Our broad clinical approach supports the complex needs of specialty patients. Specially trained pharmacy teams provide therapy-specific expertise and support to help improve engagement and outcomes. AccordantCare nurses have extensive experience with rare conditions and can provide condition-level support to manage the whole patient while ensuring costs are optimized. And Coram infusion services teams deliver specialty infusion, nutrition therapies and support services for better clinical outcomes and lower overall health care costs. In addition, our advanced analytics and digital infrastructure enables us to better engage members throughout the duration of therapy to drive adherence that leads to better outcomes and cost control. 

Have a question about our Specialty programs? Ask Us

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. Client-specific modeling available upon request.

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