Medical Benefit Management

By 2020, nearly half of all specialty medication spending will be under the medical benefit, making it critical to have a comprehensive cost management strategy in place across benefits.1

There are various approaches to managing specialty medications under the medical benefit. Utilization management programs, prior to a drug being dispensed, can help mitigate the rising cost of specialty drugs while making sure members get access to the medications they need. However many current approaches have challenges such as a manual, retrospective prior authorization (PA) process, PA not being linked to the pharmacy benefit, and a limited range of therapies managed with PA, which make it harder to enforce these strategies.

Gross Trend Bar Chart

The use of such strategies is more consistent in the pharmacy benefit: more than 80 percent of CVS Health pharmacy benefit clients utilize specialty PA to manage therapy classes under the pharmacy benefit. Within the medical benefit, retrospective controls after a drug is dispensed are also typically limited in scope. Fewer than 40 percent of payors use claim edits to ensure billed amounts matched the PA under the medical benefit.2

CVS Health has the broadest set of integrated capabilities to help clients manage specialty spend across the pharmacy and medical benefit. By analyzing the trend drivers unique to an organization, we can help payors uncover opportunities to address gaps in specialty management with an array of integrated management tools. Our solutions can help save up to an additional 19 percent on managed categories of specialty spending under the medical benefit.*

Gross Trend Bar Chart

Medical Benefit Management Overview

Prior Authorization Across Benefits

Implementing an integrated PA solution for pharmacy and medical benefits within a single portal can help save up to 7.5 percent on managed classes. This solution helps enables payors to prevent inappropriate use and control spend by ensuring that the lowest-cost, clinically-appropriate drugs are utilized first, without adding administrative hassles. It can also help ensure that PA requirements are being appropriately applied prior to a drug being administered.

We offer delegated PA services for Medicare Part B. Through a clinically-sound review process, we can manage organization determination and regulatory oversight for Medicare payors.

Medical Claims Editing and Pricing

Medical claims editing and pricing helps provide accuracy for specialty drug claims paid under the medical benefit. This automated capability helps payors ensure that claims for specialty drugs under the medical benefit are clinically appropriate, match the approved drug and dose from the PA process, and are paid accurately. When a claim submitted for a drug does not match the quantity and dose limits included in the plan design, the claim can be edited and repriced according to the appropriate fee schedule to provide tighter cost control. This solution can save up to 3 percent in managed classes.

Site-of-Care Management

Administration of infused drugs may occur in several different settings, including hospital outpatient settings. Alternative sites, such as home or local ambulatory infusion suite, can present convenient options for patients and are lower cost for payors. With the Coram infusion network and home infusion services, CVS Health is able to facilitate infusion in these or other alternative sites and to help patients transition from one site to another, helping to save up to 1 percent in managed infusion classes. Dedicated infusion nursing teams provide personalized outreach and clinical support for members. Depending on plan design, the benefits of an alternative site of care can be reviewed with the member and prescriber or the site of care transition can be integrated into the management process. Our automated tool enables payors to transition members to lower-cost sites of care for infused specialty drugs at the time of PA.

Foundation for Medical Rebates

Our expertise, size and scope, and technology enables us to negotiate, bill and optimize rebates for high-cost specialty drugs paid through the medical benefit, a majority of which are passed on to payors.

Drug Alignment under the Pharmacy Benefit

As part of a comprehensive trend management strategy, we consult with clients to help determine if they can benefit from shifting medication dispensing and management of some oral and self-injectable therapies to the pharmacy benefit. Realignment of the drug benefit can save up to 1% on specialty drug spend under the medical benefit.

Considerations for your business
  • Do your utilization management programs work across medical and pharmacy benefits?
  • What percentage of the infusions you cover occur in the hospital setting?
  • Are you receiving rebates on drugs dispensed under the medical benefit?
Have a question about our Medical Benefit Management programs?

1. CVS Enterprise Analytics, 2016. “Medicines Use and Spending in the U.S.” IMS, April 2016.

2. EMD Serono Specialty DigestTM, 12th Edition, Managed Care Strategies for Specialty Pharmaceuticals

* Savings estimate based on implementing specialty management strategies, normalized for 1 million lives. Client-specific modeling available upon request. Savings results will vary based on a variety of factors including demographics, plan design and other programs implemented by the client.

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