Medical Benefit Solutions

Having a comprehensive cost and clinical strategy that spans medical and pharmacy benefits is essential.

Nearly half of all specialty medication spending is under the medical benefitBarclays US Health Care Distribution and Technology Specialty Market Model 2017 Update: A Focus on Biosimilar Opportunities, Jan 30, 2017., and complex conditions such as oncology often include complicated therapy regimens that are commonly billed across pharmacy and medical benefits. Having a comprehensive cost and clinical management strategy spanning across benefits helps payors better identify and manage all of these costs.

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 plan 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.

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 proprietary cross-benefit technology, Novologix®, enables a variety of strategies at the point of prescribing, featuring integrated PA and medical claims management, site of care (SOC) optimization and medical preferred drug strategies targeting high-cost drug classes including oncology.

Novologix has high adoption by health plans and high utilization by healthcare providers:As of Q2 2019; auto-approval: CVS Specialty Client Solutions and Trend Management, based on Q1-Q3 2018 data. 88% portal utilization rate among the plan’s top 100 providers: Novologix Data Warehouse, 1/2018-5/2019 (P1002340719). Top 100 providers are ranked by PA volumes and represent 50% of all PAs submitted for the plan.

47M+
health plan lives

represented in 23 plans
88%
portal utilization rate among top providers
47M+
health plan lives

represented in 23 plans
88%
portal utilization rate among top providers

Medical Benefit Management Overview

Prior Authorization Across Benefits

Adopting an integrated PA solution across pharmacy and medical benefits within a single portal can help manage utilization more comprehensively and drive operational efficiencies. This solution enables payors to prevent inappropriate use and control spend by ensuring that the lowest-cost, clinically appropriate drugs are used first, without adding administrative hassles. It can also help ensure that PA requirements are being appropriately applied prior to a drug being administered in real-time, across both benefits through a single front-end system. Novologix offers online, real-time access to an automated PA process across both benefits.

$2.16 PMPM savings
achieved for medical drug PA$2.16 per member per month (PMPM) savings achieved by Novologix clients for medical drug PA: CVS Specialty Client Solutions and Trend Management, 2018. Savings projections are based on internal data (1/18-12/18). 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. (P1002550819).

We also 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.

$2.16 PMPM savings
achieved for medical drug PA3

Medical Claims Management

Medical claims edits and pricing help provide accuracy for specialty drug claims paid under the medical benefit. Integrated Novologix technology matches claims to PA requirements and applies edits to ensure the right dose, duration and price. 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.

Site-of-Care Management

$1.36 PMPM savings
via other medical management programsCVS Specialty Client Solutions and Trend Management, 2018. Savings projections are based on internal data (1/18-12/18). 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.

Our automated tool enables payors to transition members to lower-cost sites of care for infused specialty drugs at the time of PA. Administration of infused drugs may occur in several different settings, including hospital outpatient settings. Alternative sites, such as the patient’s home or a local ambulatory infusion suite, can present convenient options for patients and are lower cost for payors. Dedicated infusion nursing teams provide personalized outreach and clinical support for members, and help them transition from one site to another if appropriate. Depending on plan design, the benefits of an alternative SOC can be reviewed with the member and prescriber or the SOC transition can be integrated into the management process.

$1.36 PMPM savings
via other medical management programs4

Foundation for Medical Rebates

Thoughtful and strategic purchasing decisions are essential to delivering lowest net cost, and we help clients move on the right opportunities at the right time. Our expertise, size and scope affords us the ability to negotiate on our clients’ behalf, and our technology solution, Novologix, provides real-time intervention at the time of PA to enable preferred drug selection. As the market changes, so do our strategies. CVS Health is taking action on biosimilars and has proven experience in supporting clients’ efforts to maximize share under the pharmacy benefit. Today, we can help clients leverage biosimilars as approvals, regulation and network acceptance gains momentum under the medical benefit.

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 provide savings opportunities based on the impacted drug classes.

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