Specialty Cost Management

Specialty is growing and changing rapidly. Innovative strategies and active management can help plans anticipate trends and control spend.

Between skyrocketing health care costs and the economic uncertainty brought on by the COVID-19 pandemic, many clients are looking for new ways to better contain specialty costs.

CVS Health® is proactively managing specialty as the key driver of overall pharmacy costs with a focus on the results that matter most to our clients and their members.

39%
average client savings
on specialty spend
CVS Caremark PBM Employer Book of Business clients with adoption of ACSF, Exclusive Specialty, Specialty Quantity Limits, and Standard and Enhanced SGM. Savings based on episode activity Q1-Q2 2020, with resolved activity as of July 29, 2020, and client-level PrudentRx savings estimates. ​For high-deductible health plans, PrudentRx savings are due to deferral of client coverage in the post-deductible and post-maximum-out-of-pocket phases.​​​ 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. (P100​6200820).

Between skyrocketing health care costs and the economic uncertainty brought on by the COVID-19 pandemic, many clients are looking for new ways to better contain specialty costs.

39%
average client savings
on specialty spend1

CVS Health® is proactively managing specialty as the key driver of overall pharmacy costs with a focus with a focus on the results that matter most to our clients and their members.

~50%
of drug spend 

is driven by specialty medications in the pharmacy benefitCVS Health Enterprise Analytics, 2016. “Medicines Use and Spending in the U.S.” IMS, April 2016 or Commercial clients, using year-end cohorts, represent Employer and Health Plan groups, January 14 to December 2018, Enterprise Analytics, March 2019.
Key factors driving trend
Increasing utilization:
  • Robust pipeline
  • Expanding indications
  • Aging populations
Increasing prices:
  • Brand-name drug price inflation
  • Higher costs for innovative drugs
~50%
of drug spend 

is driven by specialty medications in the pharmacy benefit2

Key factors driving trend

Increasing utilization:

  • Robust pipeline
  • Expanding indications
  • Aging populations

Increasing prices:

  • Brand-name drug price inflation
  • Higher costs for innovative drugs

Cost management solutions

CVS Health has a unique integrated specialty management approach that enables us to address the challenges payors face in controlling specialty spend. Core management strategies work together for enhanced cost control programs, and by layering solutions, payors can reduce spend and trend significantly.

Next generation utilization management

We offer a range of proven utilization management (UM) programs that help ensure the right drug at the right dose is prescribed to the right patient at the right time.

Our connected UM solutions include standard and enhanced Specialty Guideline Management (SGM), quantity limits (QL) and starter fill, all of which help ensure a balance of utilization and price management to achieve lower net cost. Additionally, our next generation digital engagement platform enables precise clinical interventions throughout a plan member’s journey.

Our UM approach leverages:

  • Rigorous criteria including required documentation, reduced duration of approval and embedded indication and weight-based quantity limits
  • Medical director review of complex, high-cost drugs for added clinical oversight
  • Retrospective, complex case review by a multi-disciplinary team to identify and address management challenges
  • Intelligent medication monitoring employing advanced analytics, digital capabilities and proactive support to identify gaps in care, ensure appropriate adherence, avoid wasteful spend and lower overall health care costs
4.3% decrease
in overall SGM approval ratesCVS Health Enterprise Analytics, PA Performance Dashboard (Q3 2019-Q2 2020), accessed August 10, 2020. Reflects performance of UM programs based on episode outcomes- which captures rejects (70 & 75) followed by PA (if any) and the fill outcomes. Excludes New to Market Block and claims data for Discount Card, Restricted Data, and certain other clients excluded. Actual results may vary depending on benefit plan design, member demographics, programs implemented by the plan and other factors.
23.5% decrease
in HAE approval ratesCVS Health Enterprise Analytics, UM Performance Dashboard (Q3 2019-Q2 2020), accessed August 19, 2020. Reflects performance of UM programs based on episode outcomes- which captures rejects (70 & 75) followed by PA (if any) and the fill outcomes. Actual results may vary depending on benefit plan design, member demographics, programs implemented by the plan and other factors.
4.3% decrease
in overall SGM approval rates3
23.5% decrease
in HAE approval rates4

Through ongoing surveillance and high-touch, experienced clinical review, we continue to invest in UM strategies focusing on high-cost therapeutic categories to test, learn and identify new ways to create better outcomes and experience while lowering overall health care costs.

Formulary

Formulary management is a cornerstone of cost control for payors and is key to managing spend across traditional and specialty therapies. We offer a range of formulary designs that integrate preferred drug, generic maximization and biosimilar strategies.

-9.4%
autoimmune price growth for
clients newly adopting ACSFCVS Health Enterprise Analytics. Clients aligned to our Advanced Control Specialty Formulary (ACSF) saw -3.1 percent price growth for autoimmune conditions compared to 0.1 percent for clients without the formulary. Clients that newly implemented ACSF in 2019 saw a price growth of -9.4 percent.

Advanced Control Specialty Formulary® (ACSF) currently focuses on 27 therapeutic classes. ACSF integrates multiple trend management approaches, including formulary exclusions, new-to-market drug management, tiering strategy and SGM to help ensure clinically appropriate and cost-effective therapy.

-9.4%
autoimmune price growth for
clients newly adopting ACSF5

Innovative specialty plan designs

Specialty medications are expensive and many patients utilize manufacturer copay card programs to help pay for them. These copay card dollars can circumvent plan design strategies and increase overall costs for payors.

The PrudentRx Copay Optimization Program combines an innovative specialty copay plan design strategy and best-in-class member experience to help optimize savings from manufacturer copay cards and reduce plan and member costs. The program applies to all specialty medications and includes highly utilized classes such as autoimmune, hepatitis C, multiple sclerosis and oncology. The program reduces specialty plan spend for all medications, dispensed by CVS Specialty, while keeping member's out of pocket costs at $0 regardless if a copay is available.

Exclusive network

Exclusive use of CVS Specialty pharmacy and infusion networks ensures cost-effective dispensing and helps to enable other cost management solutions.

Medical benefit solutions

Most payors spend a near equal amount on specialty drugs under the medical and pharmacy benefits. CVS Health has the broadest set of integrated capabilities to manage this spend, including prior authorization across benefits, medical claims edits and pricing, medical rebates and infusion services including SOC management.

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