Specialty utilization management
Innovative utilization management (UM) strategies that help maximize savings on specialty drugs, while prioritizing clinical integrity and member experience
Specialty medications contribute disproportionately to overall drug spend. While typically only a small percentage of plan members use them, it is critical to have rigorous UM strategies in place for these medications.
Our industry-leading UM approach balances clinical integrity with cost-effectiveness to help ensure appropriate coverage of specialty medications, leveraging robust UM criteria, high-touch clinical review, and advanced utilization oversight.
Intelligent UM controls, such as our proven Specialty Guideline Management (SGM) solution, can help ensure clinically appropriate, cost-effective specialty drug coverage. SGM includes robust prior authorization criteria for more than 500 drugs spanning 60 therapy classes.
The SGM program includes:
- Rigorous clinical assessment
- Medical director review for certain complex conditions
- Generics first
- Day-1 UM control
- Indication- and weight-based dosing limits
- Step therapy
We also offer choice and flexibility to apply even more stringent criteria for certain complex therapeutic categories with Enhanced SGM.
Our clinically sound UM helps to ensure better care and cost management.
12.4% average specialty cost savings achieved through UM in managed classes1
Solutions that focus on the entire course of therapy
Did you know?
- 14% of specialty costs are generated when therapy begins
- 86% of costs occur after the first fill and from existing utilizers2
To help manage drug spend and improve member experience, we focus on the entire course of therapy:
- Start the journey with confidence
- Eliminate waste and friction throughout
- Support when needed
Contact your account team to learn more about our utilization management solutions for specialty drugs.
Contact us
-
1 CVS Health Analytics, 2024. CVS Caremark Employer Book of Business clients with Standard and Enhanced SGM, Specialty Quantity Limits, ACSF and Exclusive Specialty. Savings based on episode activity Q1‐Q4 2023. Actual results may vary depending on benefit plan design, member demographics, programs implemented by the plan and other factors.
-
2 CVS Health Analytics, 2023. Data from Q1-Q3 2023. All data sharing complies with applicable law, our information firewall and any applicable contractual limitations. Actual results may vary depending on benefit plan design, member demographics, programs implemented by the plan and other factors.
