Specialty Cost Management
Saving money for you and your plan members is our #1 priority.
62.9% of clients had less than 10% specialty trend |
33.7% of clients had negative specialty trend |
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 – approximately 2 percent of plan members – drive over half of all specialty pharmacy spend,
62.9% of clients had less than 10% specialty trend |
33.7% of clients had negative specialty trend |
By being connected in care, we can better engage your members and their providers to ensure the right medication is covered from the start, keep unit cost low, and eliminate waste through the duration of treatment. 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. Having the right interventions to detect and take action is critical to saving money.
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 robust 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 more than 80% of our specialty patients. 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.
|
![]() |
|
![]() |
|
*Some payors have specific utilization management requirements related to PA submissions (e.g., review, submission and/or physical signature by prescribers). Specialty Expedite is only used where permissible by payor requirements and applicable law. ** Compared 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.
Would you like to learn more about how we can maximize your specialty cost savings? | Contact us |
Would you like to learn more about how we can maximize your specialty cost savings? |
Contact us |
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.
|
~$2,300
savings per targeted patient |
Watch an example of a patient's journey with IMM. We're optimizing treatment with advanced analytics during clinical moments that matter.
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. Side effects may negatively affect adherence. Continuing a member on such a therapy is wasted spend. Using our advanced data analytics and digital infrastructure, Intelligent Medication Monitoring (IMM)
Clinical interventions helped deliver ~$3,000 savings per successful intervention |
Following intervention 18% stopped or switched therapy within 60 days |
Clinical interventions helped deliver ~$3,000 per targeted patient in 90 days |
Following intervention 15% 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
using all the drivers of specialty savings
Reducing specialty trend
using all the drivers of specialty savings
Maximum savings created by a connected model
Consistent clinical rigor
Member insights and engagement
Provider connectivity
Integration enhances program impact
Ability to guarantee results
Illustrative reporting example.
Clear, 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
©2022 CVS Health. All rights reserved. Confidential and Proprietary. 75-54035A 070821