Enhancing the Specialty Management Model

Trip Hofer, Vice President of Product Development at CVS Specialty, recently spoke at the AHIP Institute and Expo on the unique challenges and opportunities of managing specialty drugs across pharmacy and medical benefits. Here, he discusses how we use technology to enhance payors’ visibility and control of their specialty pharmacy claims, which can result in streamlined processes and better cost savings.

Managing specialty drugs is more complex than managing traditional prescription drugs, and it becomes even more challenging when some of these specialty drugs are paid for under the medical benefit, when claims are adjudicated and paid for the same way as medical services.

Consider the facts:

  • Nearly half of specialty spend is administered under the medical benefit.

  • This is expected to grow in the coming years as more than one-third of drugs currently in the specialty pipeline through 2018 will be managed under the medical benefit.

  • Infused specialty medications are estimated to account for $35 billion of the specialty market, and growing.

In addition, when drugs are managed under the medical benefit instead of the drug benefit it  can complicate cost-saving utilization management programs, drive up spending and fragment patient care, not to mention create administrative burdens for the insurer and prescriber.

There is a better, more efficient way for insurers to streamline medical benefit management when it comes to specialty drugs, and at CVS Health, we are leading the way with the implementation of automated prior authorization and claims management for medical benefit specialty medications through a proprietary technology called Novologix®.

Through our approach, we enable a seamless process that starts at the point of prescribing, where a web-based portal verifies patients’ benefits and eligibility for certain medications. In addition, the technology integrates the prior authorization process and can also help identify clinically inappropriate dosing of medications and adjust the claims before adjudication. As part of this, we can also use the technology to help direct patients to the optimal and most cost effective site of care for infusion therapy.

This approach can produce results that include:

  • Savings of up to 19 percent for specialty drug medical spend;

  • $40 million in total savings in 2016 for a typical health plan covering one million lives from automated prior authorization;

  • Improved efficiency of prior authorization for providers, patients and the plan sponsor; and

  • Up to $7.5 million in savings when insurers help guide members away from more expensive hospital outpatient sites to alternate sites for high quality infusion care.

For more information on how CVS Health is working to ensure consumers have access to affordable medications, visit our Rising Drug Prices information center. And to stay informed about the most talked-about topics in health care, register for content alerts and our bi-weekly health care newsletter.