Prior authorization
Better value by ensuring coverage is clinically appropriate and cost-effective
Prior authorization (PA) is an important tool for promoting clinical integrity, controlling costs, and keeping pharmacy benefits affordable. We use it to help ensure covered prescriptions are clinically appropriate and cost-effective from the onset of therapy and throughout a plan member’s treatment journey.
We process millions of PA requests each year and are committed to continuously updating our processes to enable a smoother, more efficient experience for members, providers, and pharmacists. We do this by:
- Ensuring clinical integrity
- Creating a balanced utilization management (UM) approach
- Leveraging technology such as our smart logic PA for GLP-1s
- Using digital engagement to enhance visibility into the process
14M+ PAs processed in 2022
The CVS Caremark Guide: Best Practices in Prior Authorization
Case study
What is smart logic PA?
Our smart logic PA helps prevent off-label coverage of GLP-1s approved to treat type 2 diabetes. See how it helped one client reduce spend by 11% in just two months.
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CVS Caremark.
Employer Case Study: Using smart logic prior authorization to control spend for GLP-1 diabetes medications.
Situation.
A government employer with more than 150,000 members was seeing a sharp rise in claims for GLP-1s approved to treat type 2 diabetes.
These drugs are sometimes prescribed off-label for weight loss.
The employer needed to rein in spend on this drug class in order to keep premiums affordable.
Solution.
Smart logic prior authorization.
When we receive a claim for a diabetes GLP-1, smart logic prior authorization leverages clinical rules and information we already have about a member.
It looks for three specific parameters: an ICD code indicating a diabetes diagnosis, previous use of a non-GLP-1 type 2 diabetes medication, and previous use of diabetes supplies.
If the smart logic criteria are met, the medication is covered with no member or physician disruption.
If the criteria are not met, further information and review is needed.
Results.
In just two months, the employer saw over 7,000 fewer utilizers in this class.
$7.5 million in savings in the GLP-1 class.
11% decrease in overall net spend.
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Contact your account team to learn more about how we’re innovating PA to help control costs, improve efficiency, and smooth friction.
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