Ensuring clinically appropriate utilization for autoimmune therapies

Drugs for autoimmune (AI) conditions such as inflammatory bowel disease, psoriasis and rheumatoid arthritis account for a growing portion of pharmacy and medical drug spend. One study found that, while AI conditions affect only 1 percent of commercially insured plan members, the category accounts for nearly 20 percent of drug spend.¹

As the specialty landscape evolves, we continue to enhance our utilization management (UM) strategy to meet the demands of a fast-paced market by closely monitoring trends and the drug pipeline. Our continual surveillance means we have the most up-to-date criteria to ensure cost-effective and clinically appropriate coverage of specialty medications while promoting patient safety.

The industry is shifting towards requiring documentation over attestation for prior authorization (PA). Our connectivity to electronic health records (EHR) helps us ensure that PA requests are submitted promptly with clinically accurate data. By using information from the EHR as the source of truth for PA submission and aligning PAs to specialty UM criteria, we can help ensure coverage is based on accepted practice guidelines and accurate data.

CVS Caremark has made recent changes to our UM program for autoimmune therapies. As of July 1, documentation — such as chart notes, lab test results, medical records, claims history — is required for PA requests for all AI drugs, and documentation of efficacy for continued therapy. The process has been streamlined to ensure an optimal experience for patients and providers.

Here’s how the experience would look for a member with rheumatoid arthritis (RA) and her prescriber:

• 4.3%
  increase in AI denial rates
• 23.6%
  denial rate²

Clinical integrity and criteria

We maintain the highest clinical integrity with our UM controls by ensuring criteria are supported by medical evidence and our UM processes are accredited by third-party organizations, including URAC. Criteria are developed by clinicians (pharmacists, medical directors), validated by external physician specialists, and approved by an independent National Pharmacy & Therapeutics Committee.

EHR connectivity leads to
increased control over utilization, higher denial rates

• Visibility
  to accurate and relevant clinical data
• Immediate
  initiation of PA process
• Minimized
  reliance on provider attestation*

CVS Caremark+
CVS Specialty 

4.1%
Higher final denials when PA requests are submitted using data from EHR and aligned to Specialty UM criteria**

Our clinically sound coverage decisions help ensure durable denials that stand up to appeals.

*The AI class includes inflammatory bowel disease, psoriasis and rheumatoid arthritis. AI drugs impacted as of July 1, 2021, include Actemra, Cimzia, Cosentyx, Enbrel, Entyvio, Humira, Ilumya, Kevzara, Kineret, Olumiant, Orencia, Otezla, Remicade-Avsola-Inflectra-Renflexis, Rinvoq, Rituxan-Ruxience-Truxima-Riabni, Siliq, Simponi, Simponi Aria, Skyrizi, Stelara, Taltz, Tremfya, Tysabri, Xeljanz and Xeljanz XR.

**Some payors have specific utilization management (UM) requirements. If the PA is closed for no response or denied for lack of information, the MD may submit the required documentation for re-review; an appeal is not required.

The source for data in this document is CVS Health Enterprise Analytics, unless otherwise noted.

CVS Health uses and shares data as allowed by applicable law, and by our agreements and our information firewall.

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Health.

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