- Programs & Services
Specialty Cost Management
Specialty is growing and changing rapidly. Innovative strategies and active management can help plans anticipate trends and control spend.
Specialty cost management is a top concern for payors. Not only do specialty brand drugs carry a high price tag, management is complicated by factors unique to specialty. Spend for specialty drugs spans medical and pharmacy benefits, many drugs have multiple indications, and patients have complex medication regimens that may include traditional drugs as well as specialty pharmaceuticals. Comprehensive management of specialty pharmacy spend requires both effective cost control strategies, as well as comprehensive patient care management.
Core 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. By layering solutions, payors can reduce spend and trend significantly.
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. Advanced Control Specialty Formulary (ACSF) offers payors additional tools such as removals of certain high-cost drugs, day-one control of new products, and line extensions until they are reviewed for clinical advantages, to further help payors manage specialty costs. ACSF can help save up to 4 percent across pharmacy spend. Indication-based formularies and outcomes-based contracting for specific categories help clients tie drug cost to the value it delivers in treating a condition. We continually evolve formulary strategies to enable quick response to market trends.
Exclusive use of CVS Specialty pharmacy and infusion networks ensures cost-effective dispensing and helps to enable other cost management solutions.*
We also offer the CVS Specialty Copay Card Program which helps maximize savings with a two-part strategy to address the impact of manufacturer copay cards on trend. The first component, True Accumulator, ensures that only the actual cost that the member pays is applied towards their deductible. The second component, plan design optimization, leverages the value of copay cards to enhance program savings by increasing the copay to optimize the value of the manufacturer program. The two components combined, can save up to 5 percent on pharmacy costs.
We offer a range of utilization management (UM) programs, which help ensure that the right drug is being prescribed to the right patient at the right time, such as Specialty Guideline Management, which deliver up to 6 percent in savings, and age and disease appropriateness reviews. Clients can achieve even tighter cost control for targeted therapeutic categories with our Enhanced Specialty Guideline Management program. Under this program, we evaluate each prescription in the context of the patient’s condition and point in their health care journey rather than as an individual event or prescription, creating more opportunities to manage trend and improve outcomes.
Our UM programs encourage the use of lower-cost, clinically appropriate alternatives with Step Therapy and generics first, delivering up to 2 percent in pharmacy spend savings. Other solutions such as Quantity Limits can save up to 1 percent.
Medical Benefit Management
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, infusion services including site of care management.
Considerations for your business
- Have rising prices and utilization for specialty medications increased spend for your plan?
- Do your formulary and utilization management programs direct utilization toward the most cost-effective treatments?
- Has your plan maximized utilization of available specialty generics and biosimilars?
Have a question about our Specialty Cost Management programs?
Other Specialty programs
Spend under the medical benefit comprises half of specialty spend for payors. Our differentiated solutions, including automated prior authorization across benefits, site of care optimization and claims editing help enable payors to view and control specialty costs under the medical benefit effectively.
Our broad clinical approach supports the complex needs of specialty patients. Specially trained pharmacy teams, including pharmacists and nurses, provide proactive therapy-specific expertise and support, to improve engagement and outcomes. Nurses have extensive experience with rare conditions and can provide condition-level support to manage the whole patient, including comorbidities.
All the savings and/or trend changes discussed herein will vary based on a variety of factors, including demographics, plan design and programs adopted by the client. Client-specific modeling available upon request.
* Where allowed by law. In-store pick up is currently not available in Oklahoma and West Virginia. Some states require first-fill prescriptions to be transmitted directly to the dispensing specialty pharmacy. Products are dispensed by CVS Specialty and certain services are only accessed by calling CVS Specialty directly. Certain specialty medication may not qualify. Services are also available at Long’s Drugs locations.
Unless otherwise noted, all data is from CVS Health Enterprise Analytics.