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Enduring specialty cost savings with clinically sound therapy decisions

Accredited UM, EHR connectivity deliver durable denials


Prem Shah, Executive Vice President, Chief Pharmacy Officer


Specialty costs are continuing to rise as a result of manufacturers increasing list prices, a robust pipeline of new specialty products approved by the U.S. Food and Drug Administration (FDA), and the expansion of indications for current specialty medications. Specialty utilization management (UM) is becoming a major point of focus for all plan sponsors.

Some are trying to achieve savings through aggressive UM practices which deny large numbers of prior authorization (PA) requests – as many emerging specialty management vendors claim to do. This narrow focus does not realize cost savings, and it is flawed because it may not deliver enduring cost savings. Therapy denials based on UM practices not rooted in sound data and backed by rigorous clinical criteria can be overturned on appeal, simply creating an illusion of savings.

That is why we intentionally overhauled our UM approach to stay ahead of the market and offer payors real and enduring savings. And the very first step in this is enhanced, clinically appropriate UM criteria. We are relentless in our focus on clinical rigor and standards of care to help drive optimal outcomes for plan members contributing to an overall reduction of health care costs.

Our UM criteria has been reviewed by external experts for appropriateness, measured against our competitors, and we are transparent in how we measure it – how our therapy denials compare to those of our competitors.


Formulary Designs and UM Criteria

Based on FDA labeling, current clinical guidelines for standard of care and evidence-based medical literature

  • Developed by pharmacists on our clinical development team
  • Reviewed by our medical direcors and external physican specialists
  • Approved by an independent national pharmacy and therapeutics committee


Our UM strategies are designed to maintain the highest level of clinical integrity while helping manage spend, and backed by accreditations from independent, highly respected organizations that establish their own quality standards and performance measures, including URAC and the National Committee for Quality Assurance (NCQA).

Often accreditations are cast as important only to patient safety and quality of care. While it is true that such accreditations reflect the highest standards of patient care and safety, that is not the entire picture. To be accredited, UM criteria must be based on labeling by the FDA, current clinical guidelines for standard of care, and evidence-based medical literature.

We surround this with surveillance and analytics and reinforce it with digital connectivity.


This means we can help ensure that members get coverage to start on the lowest cost, most appropriate therapy, every time.


Process Enhancements Lead to More Effective UM

Data and analytics

  • Proactive pipeline and marketplace surveillance
  • Member data before and throughout therapy

Digital connections

  • 85% digital engagement to influence member behavior
  • EHR connectivity improves durable denials

Most effective criteria

  • Specialized experts, MDs on staff, and independent 3rd party review Transparency in criteria and impact
  • Highest clinical standard


Our systems are connected with provider electronic health records (EHRs), which enables us to better manage members’ clinical journeys. This connectivity is here today; we currently can connect with almost 70 percent of specialty patients, and nearly a third can be fully managed with EHR connectivity, including processing therapy referrals. This allows our specialty pharmacies to securely gather appropriate member information, including insurance, lab work, and diagnosis codes which minimizes additional outreach to prescribers and reduces reliance on provider attestation. Our connectivity enables us to validate treatment without need for additional prescriber outreach and ensure the appropriate medication is being used at the right time, starting therapy with certainty. With our EHR connectivity, we can deliver better UM outcomes that are also a better experience for physicians and patients. This means we can deliver a 2.4 percent higher final denial rate for new specialty treatments. And this only includes final denials after all appeals.


EHR Connectivity to Validate Treatment

  • Visibility to accurate and relevant clinical data
  • Immediate initiation of PA process
  • Eliminate reliance on provider attestation*
  • 50% of PAs submitted without additional prescriber outreach*
  • 2.4% higher final denial rate** with more clinically accurate PA submissions


*Some payors have specific utilization management requirements related to prior authorization submissions (e.g. review, submission and/or physical signature by prescribers). Specialty Expedite is only used where permissible by payor requirements and applicable law. ** compared with providers not enrolled.

In addition, 85 percent of eligible specialty patients have opted into digital communications. This means we can connect with members anytime, tailor our outreach to each member’s preference, and be able to speak directly with them to help ensure therapy appropriateness and optimize supply.


Our accredited, clinically rigorous UM criteria helps prevent unnecessary specialty utilization from the start by ensuring durable denials. In addition, we can reach members where they are and adapt our message to them. We can do this in a way no one else can because of our capabilities and the investments we have made in enhancing our processes.


All data sharing complies with applicable law, our information firewall and any applicable contractual limitations.

Savings projections are based on CVS Caremark data. Actual results may vary depending on benefit plan design, member demographics, programs implemented by the plan and other factors. Client-specific modeling available upon request.

Data source, unless noted otherwise, CVS Health Enterprise Analytics, 2021.