Cracking the cost-care code: Supporting complex conditions without compromise

Plan sponsors are no stranger to balancing rising pharmacy costs and helping members with complex conditions get the care they need. Unfortunately, this juggling act is only going to get harder. Recent reports predict that employer coverage costs could rise nearly 10% in 2026.¹ And specialty medications now make up over half of drug spend, yet only account for 2% of prescriptions.²

At CVS Caremark^®, cost management and compassionate care go hand in hand. We partner with plan sponsors on sustainable solutions, so we can focus on supporting members on their journey to better health.

Humanizing high-cost care decisions

Members with rare, chronic or complex conditions like cancer or multiple sclerosis often need life-saving, but expensive, medications. These members cost four times more than the average.³ Supporting them is not only the right thing to do — it’s solid business practice. Covering less care can actually lead to higher long-term costs, from emergency room visits to absenteeism and disability. 

Bringing a holistic approach to health care

CVS Caremark’s customized, clinical-first strategies strike the right balance between helping clients meet cost targets and providing members with the quality health care they need. Our solutions center on three main areas — formulary, individualized client support and technology.

1. Predictive analytics and precision formulary

Our Clinical Pipeline Services team continuously tracks drugs in development like GLP-1s, gene therapies and biosimilars. We share these insights with clients, so they’re up to date on new treatments and their impact on plans and costs.

We’re also the industry leader in adopting biosimilars and generics to control drug spend without compromising care. We were the first pharmacy benefit manager (PBM) to remove Humira® from our formulary and replace it with a biosimilar for a $0 copay, saving clients and members money.

2. Clinical advisor support

Our clinical advisors regularly review data from prescription and medical claims, lab results, and demographic and biometric information. They find any gaps in care and recommend customized programs to keep members with complex conditions motivated, adherent and on track. These may include programs like Accordant®, CVS Weight Management™ and Transform Diabetes Care®.

These solutions give members personalized interventions like one-on-one nurse support, nutrition planning, medication reminders and drug counseling. Clients see the benefits through improved outcomes and lower medical costs. 

3. Member-focused technology and care

We’re integrated with electronic health records so providers have immediate access to drug costs and lower priced alternatives. We use technology to automatically route prior authorization (PA) requests, reducing the average handle time per case.

Our smart digital tools help members track their medication status, refills and PAs. We also proactively contact members who may need reminders or extra help for their condition through their preferred channels. Together, these experiences promote simplicity, savings and satisfaction for members and clients.

Outcomes that matter

The results of our approach are clear: smarter strategies, tailored interventions and technology lead to improved health outcomes, satisfaction and savings.

• $24.3M annual medical cost savings with Transform Diabetes Care⁸
• ~35% decrease in diabetes-specific drug spend⁹
• $3,723 savings per member per year with Accordant Rare⁵
• 93% overall member satisfaction, 96% client satisfaction^{10, 11}

Compassion and cost control can coexist

The push and pull between cost and quality care is real. With the right PBM, clients can be both compassionate and fiscally responsible.