Data Proves Success of National CooperativeRx Specialty PA Program

National CooperativeRx’s pledge to our members is to ensure quality pharmacy benefit programs, plans, and service. Thus, we are constantly looking for opportunities to add value for our membership. In 2023, the Cooperative initiated an in-house specialty prior authorization (PA) program. Our goals for the Specialty PA Program are to improve patient and prescriber experience, improve quality, and ensure cost-effective care for participants. 

Now in our third year of the program, we can look back on the data from the first two years as confirmation of its success:

• Average turnaround time of two days for prior authorization case review.
• Our trend has consistently been lower than industry benchmarks since the program’s inception. In 2024, an industry specialty trend benchmark was 7.2% compared to 2.5% for National CooperativeRx. This translates to a cost avoidance of $25 million in 2024 across the Cooperative.
• We have realized a 20% decrease in cases overturned at Federal External Review, with fewer cases being sent for appeal, validating that the quality of our clinical decision-making is minimizing unnecessary delays in care.
• We receive positive feedback on our pragmatic approach, which results in an enhanced experience for patients and providers. For example, one patient called us with a question about the denial of his case and provided additional information that made the National CooperativeRx reviewer reconsider the denial. The review was overturned to an approval on the spot. The patient was in disbelief about how easy it was to connect with our clinician and that he was not forced through a bureaucratic process to have his case reconsidered.
• Finally, we continue to collect examples of improved care, which cannot be measured in dollars and frequently requires our clinicians to go the extra mile — or ten, sometimes. In one case, a National CooperativeRx clinician noted a request for a cancer medication seemed unusual, even though it met criteria for approval. The clinician sought the advice of an independent oncologist, who agreed and made outreach to the prescriber to change to a guideline-based treatment which was much more likely to provide survival benefit for the patient.

National CooperativeRx’s Difference

Our approach strives to embody the five rights of medication use: right drug, right patient, right dose, right time, right route. Any specialty strategy — or formulary strategy in general — should start and end with that. Unfortunately, sometimes pharmacy benefit manager prior authorization programs that are designed to serve large populations of people tend to be rigid and somewhat robotic, straying from the five rights of medication use. While National CooperativeRx’s Specialty PA program is built on the framework of the CVS Caremark PA software application, there are key differences which lead to a better experience for patients and lower specialty trend for plans. 

• National CooperativeRx has one cohesive specialty PA team focused to serve the unique needs of our members. This allows us to be flexible and offer a more personalized approach in executing plan intent.
• We use common sense and clinical judgment at all levels of review. This minimizes patients and providers from being forced through an unnecessary and lengthy review and appeals process.
• Our reviews are thorough and thoughtful; our clinicians have the opportunity to work directly with providers and patients to find treatment options that provide more benefit and value.

As partners with the best interest of our shared members in mind, it is important for us all to work together. Our member groups that have the smoothest experience and the most success in the National CooperativeRx Specialty PA program are those that ensure their participants know PA requests for specialty drugs should be directed to National CooperativeRx. Additionally, these groups engage with us when participants have questions regarding therapeutic alternatives or the specialty PA process in general. We appreciate your commitment and trust as we continue to build on our success, serving more patients and providing enhanced care.