Specialty Cost Management

Saving money for you and your plan members is our #1 priority.

Given the proliferation of specialty therapies, their high cost, and the complexity of such conditions, a singular focus on any one aspect of management will not deliver the best results. Given that a small portion – 2.5 percent of plan members – drive nearly half of all specialty pharmacy spend, and that waste can creep in both at the start of therapy and during treatment, it is vital to address cost and utilization for maximum impact. Our integrated pharmacy benefit management, retail, and specialty model focuses on keeping unit cost low and making sure the right patients are on the right drugs from the beginning, and eliminate waste throughout treatment duration. In addition, we intervene when needed to ensure that treatment is still working for members, and work with prescribers to change or discontinue it if not effective.

Start therapy with certainty

Roughly 11% of pharmacy spend is generated when a member is first diagnosed and prescribed a specialty therapy.

To help ensure the right coverage from the start, our enhanced utilization management (UM) criteria are developed by pharmacists, reviewed by external physicians, and accredited by third-party organizations including URAC, an independent leader in promoting health care quality through accreditation, certification and measurement. This means any decisions about approval or denial of treatment are rooted in rigorous clinical standards. When a prescription prior authorization (PA) is first submitted for a specialty treatment most reviews are based on a simple attestation from the prescriber. Given our connectivity and interoperability, our specialty pharmacies use electronic health records (EHRs) to verify the diagnosis through actual patient records prior to approving the treatment. We can see the electronic health records for almost 70% of our specialty patients and approximately 30% of specialty prior authorization requests are submitted with information from relevant EHR records. Combined with our enhanced UM criteria, it makes it unlikely that a denial would be overturned on appeal, ensuring appropriate use, and saving payors money on high-cost therapies.

EHR Connectivity to Validate Treatment

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Visibility
to accurate and
relevant clinical data

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Immediate
initiation of
PA process

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Eliminate
reliance on
provider attestation*

Pictogram of magnifying glass Visibility
to accurate and relevant clinical data*
Pictogram of pill bottle Immediate
initiation of PA process
Pictogram of an african american doctor Eliminate
reliance on provider attestation*
50%
of PAs submitted without additional prescriber outreach*
2.4%
higher final denial rate** with more clinically accurate PA submissions
50%
of PAs submitted without additional prescriber outreach*
2.4%
higher final denial rate** with more clinically accurate PA submissions

*Some payors have specific utilization management requirements related to prior authorization submissions (e.g. review, submission and/or physical signature by prescribers). Specialty Expedite is only used where permissible by payor requirements and applicable law. ** with providers not enrolled.

We also employ our scale and expertise to deliver lowest unit cost at the therapeutic category level through strategies like formulary, generics first, and maximizing competition through biosimilars. By strategically balancing clinically rigorous UM and unit cost, we create the most value for our clients.

Eliminate waste throughout

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

The bulk of the cost occurs in the duration of a member’s therapy. By carefully monitoring every step of a member’s therapy to ensure they are on the right medication at the right dosage, that the treatment is working, and prevent unnecessary supply accumulation, we can eliminate waste and drive savings.

One way to do this is by optimizing supply management.A specialty pharmacy service performed by CVS Specialty for contracted payors. Given the high cost of specialty drugs, even a small amount of excess supply – medication that the patient doesn’t need to have on hand – can significantly add to payor cost.

Supply Management Optimization


85%

of specialty patients signed up for digital communications

Automated monitoring

identifies when a patient may be accumulating excess supply

Advanced analytics

and digital capabilities help verify supply, suggest new ship date to prevent excess accumulation

85%

of specialty patients signed up for digital communications

Automated monitoring

identifies when a patient may be accumulating excess supply

Advanced analytics

and digital capabilities help verify supply, suggest new ship date to prevent excess accumulation

***Targeted utilizers make up <2% of all specialty utilizers

Intervene when needed

Specialty conditions are complex, and therapies sometimes stop working for members. This may mean the members do not see an improvement in their conditions or their symptoms worsen. They may even not be optimally adherent to their regimen if they are experiencing side effects. Continuing a member on such a therapy is wasted spend. Using our advanced data analytics and digital infrastructure, Intelligent Medication Monitoring, can identify, and engage members who are no longer benefitting from their therapy. Through targeted interventions and proactive therapy management, we can identify gaps in care, help improve appropriate adherence, and reduce wasted spend to lower overall costs.

Intelligent Medication Monitoring

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Identify:
Therapy-specific assessments help us monitor efficacy, symptoms, pain and exacerbations.

Pictogram of clipboard Assess:
CareTeam assesses patient-reported symptoms based on clinical guidelines for time on therapy and/or indication, adherence behavior.
Pictogram of pill bottle Determining When to Intervene: 
If the patient's symptoms meet clinical criteria for the therapy being effective, we can intervene appropriately.
Pictogram of a laptop showing an online medical exam Targeted Interventions:
Investigate causes of symptom or side effects, identify opportunity for medication management, and as appropriate, engage with provider.

Clinical interventions helped save
~$2K

per targeted patient in 90 days
Following intervention
23%
stopped therapy or changed to another medication in the 90 days
Clinical interventions helped save
~$2K

per targeted patient in 90 days
Following intervention
23%
stopped therapy or changed to another medication in the 90 days


We also use the proactive and retrospective visibility to generate insights that enable us to innovate new solutions and programs to further reduce waste and lower costs.

Clearly see the benefit

Our comprehensive approach to specialty management targets every step of the process, and all the components work together to help deliver the most savings for payors. 

Reducing Specialty Trend Through Innovative Solutions

Reducing Specialty Trend Through Innovative Solutions

$100 million unmanaged spend in 2019 (20,8% Trend). With Programs in place, achieved 28,7% savings. Programs: $6.5 million Core Specialty Guideline Mangement (SGM.) – trend 14.3%. $4.9 million Specialty quantity limits – trend 9.4%. $4.4 million Advanced Control Specialty Formulary – Trend: 5%. Program opportunities for additional 18.5% savings: $6.5 million enhanced SGM – trend 1.3%. $8 million PrudenceRX – trend -6.7%. $3.8 million site of care drug benefit alignment – trend -10.5%.

Client implementing Enhanced SGM for 2021
PrudentRX copay card strategies will help mitigate futue specialty spend
Medical Specialty Management

Illustrative reporting example.

Detailed, transparent reporting enables clients to see exactly how these strategies work for your plan. We proactively monitor the pipeline of new drugs and utilization trends to provide consultative prospective reports to clients. And our retrospective data analysis help payors understand their plan spend in detail. Our goal is to deliver results and provide value, to our clients and their members, now and into the future.

Want to learn more about how our comprehensive, integrated approach to specialty management helps your plan save money? Ask Us

All data sharing complies with applicable law, our information firewall and any applicable contractual limitations.

Savings projections are based on CVS Caremark data. 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

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

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