Specialty Cost Management
Specialty is growing and changing rapidly. Innovative strategies and active management can help plans anticipate trends and control spend.
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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 |
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 benefit |
Key factors driving trend | |
Increasing utilization:
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Increasing prices:
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| ~50% of drug spend is driven by specialty medications in the pharmacy benefit2 |
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Key factors driving trend Increasing utilization:
Increasing prices:
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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% decreasein overall SGM approval rates |
23.5% decrease in HAE approval rates |
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 ACSF |
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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