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Specialty drugs account for nearly half of pharmacy spend, and managing them has become one of the most talked-about challenges in the pharmacy benefit space. At National CooperativeRx, we have a proven approach to managing specialty spend. By leveraging clinical expertise, data-driven insights, and strong member engagement, we deliver measurable success for our members. After our membership achieved a specialty trend of only 1.4% in 2023, we followed it up with a low 2.5% in 2024.
A Multi-Faceted Approach to Specialty Trend Management
Success in managing specialty trend does not come from a single strategy—it is the result of multiple layers of oversight and optimization.
Adoption of National CooperativeRx In-House Clinical Programs
The most successful clinical programs are free of misaligned incentives; they improve the quality and experience of care as well as lower costs. In January 2023, National CooperativeRx took ownership of specialty prior authorization reviews and added enhanced criteria for psoriasis reviews. These changes have strengthened the case review process, streamlined communications with both providers and patients, and increased the value of care. Additionally, our in-house Specialty High-Cost Claims Review program serves as a supplemental layer of review for specialty claims above a specific cost threshold. With 100% of our member groups participating in specialty prior authorization carveout and over 80% participating in high-cost claim reviews, combined estimated cost avoidance in 2024 totaled ~$60 million.
Our clinical programs work in tandem with our PBM partner, CVS Caremark, and its refined formularies to ensure safe and appropriate medication use. 97% of our membership utilizes CVS Caremark’s Advanced Control Specialty Formulary, which offers the greatest level of management for select specialty categories and incentivizes therapies with the lowest net cost. Additionally, with the emergence of Humira biosimilars, CVS Caremark identified the opportunity to help member groups lower costs by removing brand Humira from their formulary in April 2024. Since then, almost all our participants have transitioned to the biosimilar, leading to a significant reduction in list price and substantial savings for plan participants and member groups.
Data-Driven Oversight and Annual Reviews
Managing specialty trend requires continuous oversight and adaptability. At National CooperativeRx, our clinical team proactively monitors the specialty pharmacy pipeline using various resources, including subscription-based tools. This alerts us to emerging products and relevant clinical trials, which we assess for their potential clinical value and impact on trends. We filter this information through the unique needs of our members, developing tailored recommendations that support our strategic account team in guiding member groups throughout the year.
We are pleased to review group-specific trends, plan design, clinical programs, and edits that may contribute to member groups’ specific goals. By combining data-driven insights with thoughtful planning, we empower our members to make the best possible decisions for their pharmacy benefits. Sound plan design and utilization management ensures resources are allocated effectively and helps plans be prepared to absorb the cost of a complex or high-cost participant.
Engaged Member Groups
Our members play a crucial role in the success of our specialty drug management strategy. Their active engagement and collaboration with National CooperativeRx drive the positive outcomes we consistently achieve. By implementing recommendations and participating in specialized programs, they are optimizing their pharmacy benefits, reducing unnecessary costs, and enhancing the overall quality of care for their plan participants. Additionally, by educating their plan participants and fostering informed decision-making, they empower individuals to make smarter healthcare choices.
The ongoing developments in the specialty drug space require perpetual monitoring, anticipation, and creative thinking to manage trend. National CooperativeRx remains committed to helping our members navigate emerging challenges. Our data-driven strategies, clinical oversight, and strong member collaboration have positioned us for success in managing specialty trend. By staying engaged and proactive, our members can continue to achieve industry-leading results in specialty cost containment and patient care.
Are you maximizing your specialty drug management strategy? Contact your National CooperativeRx account representative to review your plan’s specialty trend and explore opportunities for further optimization.
