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Utilization management

CVS Caremark offers industry-leading utilization management (UM) by balancing clinical integrity with cost effectiveness to help ensure appropriate coverage of medications without compromising care and member experience. Our clinically sound UM approach is based on criteria that have been developed to improve experience and is designed to ensure better care and cost management for both traditional and specialty drugs.

CVS Caremark offers a full suite of options depending on your business objectives:

  • Plan design
  • Formulary strategies
  • Prior authorization (PA)
  • Step therapy
  • Quantity limits
  • Smart logic PA 

Up to $91PMPM savings on overall drug spend1

We use advanced technology and real-time decisioning to optimize our UM offerings. Smart UM is designed to ensure clinically appropriate coverage of high-cost medications while keeping costs in check. It simplifies the process for providers, eases onboarding for patients, and creates savings for plan sponsors. Prior authorization is simplified, removing unnecessary friction from the provider and member experience.

Featured solutions

Specialty UM

Multiple levers that help manage cost for industry-low specialty drug trend

Prior authorization

Getting patients started on the right therapies, faster

Supply Management Optimization

Helping members effectively manage supply on hand

Intelligent Medication Monitoring

Making connections to optimize treatment during moments that matter

Case study

Maximizing specialty savings with cost and patient management

CVS Caremark added specialty guideline management controls to help this large retailer control costs and improve care.

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CVS Caremark.

Employer Case Study: Maximizing specialty savings with cost and patient management.


Hoping to attract and retain their workforce, a retailer wanted to maximize benefits.

In reviewing their total drug spend, 55% was attributed to specialty costs.


Implemented our Specialty Guideline Management (utilization management) programs to both control costs and improve care.

Added Accordant to focus on patients using specialty medications to manage the top 13 rare or complex conditions.


12% reduction in specialty trend.

$16.8 million total savings in 2021.

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Let’s work together to find your lowest net costs


  • 1With full program adoption: Advanced Control Specialty Formulary, Specialty Guideline Management, non-Specialty Prior Authorization, Quantity Limits, PrudentRx, Hyperinflation, Exclusive Specialty and Maintenance Choice