Download CareFirst Formulary Comparison (200+ ASO)

CAREFIRST
SPECIALTY
PHARMACY
COORDINATION
PROGRAM
200+ ASO ACCOUNTS
September 3, 2014
1
PROPRIETARY AND CONFIDENTIAL
Key Takeaways
•
•
•
•
What are Specialty medications and how are they driving pharmacy
costs?
How is Specialty Pharmacy Coordination (SPC) program differentiated in
the market?
How does Exclusive Specialty support SPC and why is it the most
appropriate delivery system?
How are SPC and Exclusive Specialty Network a proactive approach to
controlling overall health care spend?
2
PROPRIETARY AND CONFIDENTIAL
Agenda
1 Overview of Specialty Marketplace
Specialty Pharmacy Coordination Program
CareFirst’s Exclusive Specialty Network
Communication Strategy
Implementation Timeline and Requirements
Appendix
3
PROPRIETARY AND CONFIDENTIAL
By 2018, Specialty Will Represent 50
Percent of all Drug Spend1
• 6 of the top 10 drugs will be specialty2
• Pipeline has ~900 specialty drugs in
development3
• 40% of patients do not adhere to their
treatment regimens4
• Inflammatory conditions such as
multiple sclerosis and cancer continue
to account for two-thirds of specialty
drug spend4
• Price inflation
TOTAL INDUSTRY SPECIALTY
SPEND1
$235B
$92B
2012
2018
30%
50%
Percent of Total Drug Spend
– AWP increase 16% to 19% per year for
certain
5
multiple
sclerosis
drugs
Specialty adherence outpaces traditional retail pharmacy by an average of 9%4
1. NHE, Artemetrx, CVS Caremark internal analysis, 2013.
2. EvaluatePharma, “World Preview 2013, Outlook to 2018 Returning to Growth”, June 2013.
3. http://www.specialtypharmacycontinuum.com/ViewArticle.aspx?d=Operations+%26+Management&d_id=496&i=November+2013&i_id=1009&a_id=24394, accessed 1/17/14.
4. URAC Specialty Whitepaper, 2011.
5. CVS Caremark Internal Data. Enterprise Analytics 2012.
4
PROPRIETARY AND CONFIDENTIAL
CareFirst Specialty Spend
•
•
•
January to June 2014:
– 1.7% of utilizing plan members
– 28.5% percent of the total drug cost
Members who use specialty drugs also use the overall health care
system at higher rates and are among the costliest to treat
Specialty drugs can help to slow disease progression, prevent adverse
events and improve the quality of life for members beyond what was
possible without them
Integration of medical and prescription lowers overall health care costs
Source: Specialty RxInsights Report & CareFirst Specialty Pharmacy Coordination Program Guidelines
5
PROPRIETARY AND CONFIDENTIAL
What are Specialty Medications?
PRODUCTS THAT MAY HAVE SOME COMBINATION OF
THE FOLLOWING CHARACTERISTICS:
• Treat chronic, complex and/or rare
disease states
• Require special handling, storage
inventory and/or administration
• U.S Food and Drug Administration
(FDA)-mandated safety programs
• Require clinical assessment to optimize
safety and adherence
• Limited distribution
• High cost
6
PROPRIETARY AND CONFIDENTIAL
Top 10 Diseases and the PMPM Cost of Specialty Drugs
Top 10 drug classes comprise 93.5% of your total drug cost
PMPM=Per member per month; HIV=Human immunodeficiency virus; RA=Rheumatoid arthritis; MS=Multiple Sclerosis; HEPC or HCV=Hepatitis C Virus;
ONCOL=Oncology or cancer; INFERTIL=infertility; HGH=human growth hormone; PAH= pulmonary arterial hypertension; CF=Cystic Fibrosis
Source: Specialty RxInsights
7
PROPRIETARY AND CONFIDENTIAL
About Three Million Adults In The United
States Are Infected With HCV1
Baby boomers are five
times more likely to have HCV1; CDC
recommends they get tested2
99% of HCV patients
have a directly-associated comorbid condition4
Genotype 1 accounts for 70% to 75% of all
infections in the United States3
1 in 4 people infected with HIV are also infected
with HCV5
Chronic Hepatitis C (CHC) infection is the
leading indication for liver transplants*3
HCV prevalence
varies widely from state to state, ranging from
1.3% to 0.4%6
Hepatitis C treatment is complex and presents a number of adherence challenges.
*In the United States
1. http://www.cdc.gov/features/vitalsigns/hepatitisc/, accessed August 28, 2014.
2. http://www.cdc.gov/knowmorehepatitis/Media/PDFs/FactSheet-Boomers.pdf, accessed August 28, 2014.
3. http://www.cdc.gov/hepatitis/HCV/HCVfaq.htm, accessed August 28, 2014.
4. Louie KS, et al. The high comorbidity burden of the hepatitis C virus infected population in the United States. BMC Infectious Diseases 2012, 12:86 doi:10.1186/14712334-12-86
5. http://www.cdc.gov/hepatitis/Populations/hiv.htm, accessed August 28, 2014.
6. Milliman Report, “Health Care Reform and Hepatitis C: A Convergence of Risk and Opportunity”, December 10, 2013
8
PROPRIETARY AND CONFIDENTIAL
Disease Progression Will Occur Without
Treatment
•
•
•
HCV infection is a leading
cause of cirrhosis, liver cancer
(hepatocellular carcinoma;
HCC) and liver
transplantation1
10% to 20% of chronic HCV
patients will develop cirrhosis
and up to 5% will progress to
liver cancer1
HCV affects nearly 50% of all
liver transplants2
ANNUAL COSTS PER PATIENT BY
CONDITION3, 4
$577,000
$160,000
$62,000
LIVER CANCER
CIRRHOSIS
LIVER
TRANSPLANT
SVR* reduces risk for HCC, end-stage liver disease, liver transplant, diabetes and mortality.5
*Sustained Virologic Response
1. H. Razavi1, A. El Khoury2, E. Elbasha2, C. Estes1, K. Pasini1, T. Poynard3, R. Kumar2, Chronic Hepatitis C Virus (HCV) Disease Burden And Cost In The United
States, Hepatology. Jun 2013; 57(6): 2164–2170. 2. Wiley (2012, December 6). Aging hepatitis C population escalates demand for liver transplantation. ScienceDaily.
http://www.sciencedaily.com/releases/2012/12/121206121902.htm. Accessed August 28, 2014. 3. Milliman Report: Consequences of Hepatitis C Virus: Cost of a Baby
Boomer Epidemic of Liver Disease, May 2009; 4. Milliman Report: 2011 U.S. Organ and Tissue Transplant Cost Estimates and Discussion.
5.
http://www.amcp.org/WorkArea/DownloadAsset.aspx?id=16750. Accessed August 8, 2014.
9
PROPRIETARY AND CONFIDENTIAL
Launch Pricing
Sovaldi™
$30,000
Revlimid®
Tecfidera®
Incivek®
Copaxone®
Enbrel®
Humira®
Source: Launch pricing available online.
This slide contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS/caremark.
10
PROPRIETARY AND CONFIDENTIAL
Agenda
Overview of Specialty Marketplace
2 Specialty Pharmacy Coordination Program
CareFirst’s Exclusive Specialty Network
Communication Strategy
Implementation Timeline and Requirements
Appendix
11
PROPRIETARY AND CONFIDENTIAL
Specialty Pharmacy Coordination (SPC)
•
•
•
Integration of Specialty Pharmacy and Care Management Teams
High-touch, high quality management and support to assure the
best outcomes
24 x 7 telephonic access to a specialty pharmacist or nurse
– Support member questions
– Help manage side effects
– Reduce the possibility of unnecessary emergency room visits or
hospitalizations
•
Links with Complex Case Managers (CCMs), Behavioral Health
Case Managers or Local Care Coordinators (LCCs) for members
managing other co-morbidities to holistically manage the chronic
condition
Integration with iCentric to assure continuity of care with
primary care physician (PCP)
12
PROPRIETARY AND CONFIDENTIAL
Identification of Members
•
Analysis of pharmacy and medical claims data
– CVS Caremark Specialty Member:
• Higher engagement outcomes because of the existing relationship with
the CVS Caremark Specialty Team
– Non-CVS Caremark Specialty Member:
• Intro letter mailed to the member
• Engagement outreach 5 to 6 days post letter (if phone number is on file)
•
Service requests placed for the SPC Program by CareFirst care
coordinators (LCCs and CCMs)
33% higher engagement rates with Exclusive Specialty in place
Source: Accordant data
13
PROPRIETARY AND CONFIDENTIAL
SPC Offers Two Distinct Levels of Service
SPECIALTY PHARMACY
•
Access to specialty medication
•
Medical/pharmacy benefits verification
•
Financial assistance consultation
•
Injection training coordination
•
Medication/dose appropriate
management
•
Education on adherence and side
effects
CARE MANAGEMENT
•
Aligned with CareFirst Case
Managers
•
Unique care plan including all
clinical factors
•
Robust disease specific/co-morbidity
education
•
Self-management, “stay healthy”
behavior
•
Disease complication prevention
•
Safety compliance
•
Drug optimization
•
Drug-drug interaction review
•
Member support/coping skills
•
Inventory coordination to help reduce
waste
•
Care Coordination
•
Refill reminders
•
Coordination of services, resources
and interventions.
CareFirst’s integration between Specialty Pharmacy and Care Management is
unmatched in the market
1. CVS Caremark Data Warehouse 2010-2011 March 2012, CVS Caremark Specialty Analytics.
14
PROPRIETARY AND CONFIDENTIAL
Our Clinical Model Extends Care
Management Impact: MS Example
SYMPTOMS
SELF CARE
•
•
•
•
•
•
•
•
•
Flare-ups
Pain
Fatigue
Disease progression
SPECIALTY PHARMACY:
MEDICATION MANAGEMENT
•
•
•
•
Self-injection training
Physical activity
Nutrition
Fall prevention
Adherence reinforcement
CO-MORBIDITIES
Adherence
Side effects
Safety
Financial assistance
Patient
• Depression
• Diabetes
• Osteoporosis
CARE OPTIMIZATION
•
•
•
•
Medical equipment
Transportation
Caregiver support
Transition to home
High-touch, high quality management and support to assure the best outcomes
15
PROPRIETARY AND CONFIDENTIAL
How Care Management Supports Ellen
• Ellen, 39, is married to
Tom and their son is in
first grade
• She was diagnosed with
MS three years ago
• She worries that her
condition will end her
accounting career
• Recently, her flare-ups
have been more frequent
and more severe
• Her last flare-up required
a hospital admission
Patient story is represented for illustrative purposes only. Any resemblance to an actual individual is coincidental. All data sharing complies with applicable firewall and
privacy laws.
16
PROPRIETARY AND CONFIDENTIAL
Coordinated Pharmacist and Nurse Care
1
2
Ellen’s PCP prescribes
new therapy
New prescription reviewed
for appropriateness; prior
authorization obtained
4
3
Ellen’s MS CareTeam representative calls
• Educates Ellen on her new therapy and
introduces Care Management; schedules call
• Offers to ship prescription to Ellen’s home,
office or local CVS/pharmacy for pick-up*
5
Ellen’s nurse calls in two weeks;
her flare-up is subsiding and she
has a PCP appointment to
discuss her depression
Care Management nurse calls Ellen to
assess condition and create a Disease
Management Plan (DMP)
• Alerts PCP by mail to signs of depression;
PCP views DMP in iCentric
6
7
Before the next refill, Ellen’s
CareTeam calls to assess adherence
and side effects with the new therapy
Ellen’s nurse calls to follow up and
assess continued progress; updates
record in iCentric
Purple outline indicates Care Management services
Blue outline indicates Specialty Pharmacy services
Patient story is represented for illustrative purposes only. Any resemblance to an actual individual is coincidental. All data sharing complies with applicable firewall and privacy
laws.
*Where allowed by law. In-store pick up is not available in Arkansas, Oklahoma and West Virginia. Some states require first fill prescriptions to be transmitted directly to the
dispensing specialty pharmacy. Other restrictions may apply.
17
PROPRIETARY AND CONFIDENTIAL
Agenda
Overview of Specialty Marketplace
Specialty Pharmacy Coordination Program
3 CareFirst’s Exclusive Specialty Network
Communication Strategy
Implementation Timeline and Requirements
Appendix
18
PROPRIETARY AND CONFIDENTIAL
What is Exclusive Specialty Pharmacy?
Specialty Pharmacy Coordination services can be accessed in two ways:
• Through an Open Specialty Network (where members use any pharmacy in our
network that is authorized to fill a specialty prescription) OR
• Through the Exclusive Specialty Pharmacy Network (CVS Specialty Pharmacy or
OncoSource Rx Specialty Pharmacy)
Exclusive Specialty Pharmacy Network members MUST fill their specialty
medications ONLY through CVS Caremark Specialty Pharmacy or OncoSource
Rx Specialty Pharmacy
•
CVS Caremark and OncoSource were selected as our specialty network based on their
ability to offer greater support and personalized services by a team of skilled clinicians .
CVS Caremark Specialty Pharmacy provides services and skilled clinicians for all specialty
drugs
OncoSource Rx is a Cardinal Health specialty pharmacy, located in Columbia, MD, with
experienced professionals in drug therapies requiring “specialty” drugs. These areas include
oncology and related supportive care, in addition to rheumatology, gastroenterology and other
auto-immune diseases.
The effectiveness of the Specialty Pharmacy Coordination Program is substantially
improved when specialty drugs are filled within the Exclusive network.
19
PROPRIETARY AND CONFIDENTIAL
Exclusive Specialty Pharmacy Network Selling
Points
• Experienced clinical support to help improve member adherence and
safety
• Consistent and proactive care management
• Flexible access to specialty medications through the CVS Caremark
Specialty Connect™ Program
• Access to limited distribution specialty products
• 33% higher member engagement in the Specialty Pharmacy Program
when members are using CVS Caremark Specialty Pharmacy
• Better management of specialty spend to lower overall health care
costs
• Available at no additional cost to the account
Exclusive Specialty supports CareFirst’s PCMH and TCCI initiatives
20
PROPRIETARY AND CONFIDENTIAL
Specialty Connect™: Expanded Choice, Greater Access
to Specialty Medications and Services
THE CHALLENGE: TRADITIONAL RETAIL FAILS TO MEET MANY SPECIALTY PATIENTS’ NEEDS
• 25% turned away/inadequate guidance1
• 7% to 10% fewer patients compliant to therapy2
• 20% fewer patients on therapy after one year2
OUR APPROACH: SIMPLIFIES ACCESS TO SPECIALTY PHARMACY
CHOOSE WHERE TO SEND
PRESCRIPTION
CVS/PHARMACY*
SPECIALTY
PHARMACY
RECEIVE 24/7 PERSONALIZED
EDUCATION AND SUPPORT
THERAPY-SPECIFIC
SPECIALTY CARETEAMS
COUNSEL PATIENT
CHOOSE DELIVERY LOCATION
CVS/PHARMACY*
HOME/
LOCATION OF
CHOICE**
1. 2011 New England Opinion focus group of specialty patients, calls to 150 retail pharmacies (CVS and competitors) on January 13-15, 2012 2. JP Morgan, Gill’s Guide
to Specialty across the Rx Channel, May 2012. *In-store pick up is not available in Arkansas, Oklahoma and West Virginia. Some states require first fill prescriptions to be
transmitted directly to the dispensing specialty pharmacy. Other restrictions may apply. **Where allowed by law
31856
21
PROPRIETARY AND CONFIDENTIAL
Specialty Connect™ in Action:
Improving Percent of Adherent Patients
PERCENTAGE OF OPTIMALLY ADHERENT PATIENTS USING CVS/PHARMACY
•
Only company that seamlessly integrates local
pharmacists
with skilled
specialty
staff
PILOT
STORES BEFORE
SPECIALTY
CONNECT
13%
12-MONTH PILOT RESULTS
improvement
79%
66%
CVS Caremark
Specialty Pharmacy
Adherence
50%
of patients preferred
to pick up at retail
Source: CVS/caremark internal analysis, 2013.
22
PROPRIETARY AND CONFIDENTIAL
Agenda
Overview of Specialty Marketplace
Specialty Pharmacy Coordination Program
CareFirst’s Exclusive Specialty Network
4 Communication Strategy
Implementation Timeline and Requirements
Appendix
23
PROPRIETARY AND CONFIDENTIAL
Communication Strategy
MEMBER AND
PROVIDER
OUTREACH
INITIAL CLINICAL
ASSESSMENT
60 days prior to launch
(member mailing)
Specialty CareTeam
onboards member
• Targeted member mailing and
phone outreach to transition the
member to specialty pharmacy
• Proactive clinical assessment
performed by specialty
CareTeam to identify
individual service and
education needs
• Member is notified of the added
access and convenience of using
• Shipment is confirmed and
Exclusive Network pharmacy
• Targeted contact with providers
of impacted members who need
to change their specialty meds to
the Exclusive Network
CLINICAL
REASSESSMENT
Ongoing clinical assessment
• Member re-evaluated by
Specialty CareTeam to identify
any new issues or barriers
with the prescribed treatment
regimen, including: adherence,
side effects and response to
treatment
scheduled
24
PROPRIETARY AND CONFIDENTIAL
Mailings Only to Those Who are Not Currently
Using CVS Caremark or OncoSource
•
•
Mailings are only going to those employees who are NOT currently using CVS Caremark
Specialty Pharmacy or OncoSource Rx Specialty Pharmacy (our Exclusive Specialty Network)
It is estimated that less than 1% of members in a group will need to be contacted about changing
to a pharmacy in the Exclusive Specialty Network
Account Example with 5,000
Employees
Sample Account of
5,000 Employees
Count of Members
40 members will not receive letters; they
can stay with their current provider
CVS Caremark
30
OncoSource
10
Other Network
Pharmacies
38
TOTAL
78
38 members will receive a letter indicating
they need to move to CVS Caremark or
OncoSource Rx (depending on the drug
they are taking; see CareFirst Specialty
Drug List) (two members in the original
data pull had termed )
Most employees are probably already using a pharmacy in the CareFirst Exclusive Specialty Network
Estimated less than 1% of employees will have to be contacted
25
PROPRIETARY AND CONFIDENTIAL
Key Member Deliverables
Communication
Member Notification: CVS
ONLY
Description
60 day pre-notification letter
which informs members:
1. Their specialty medications
can ONLY be filled at CVS
2. Outlines the benefits and
resources available
Timing
Mailed Letter Notifications and following
support calls will launch in 3 phases to ensure
no member is missed:
Phase
Member Notification:CVS
and OncoSource RX
Follow-up Support Calls
60 day pre-notification letter
which informs members:
1. Their specialty medications
can ONLY be filled at CVS or
OncoSource RX
2. Outlines the benefits and
resources available
Member support calls occur the
week after members receive
their notification letter:
1. Ensures the member
received and understands
the letter
2. Offers support for managing
the member’s condition
3. Collect member demographic
information
4. Connect the member with a
nurse or complete a new
program questionnaire if the
member doesn’t have time
to speak to a nurse
Target
Range
Data Pull
Date
Launch
Date
Followup
Support
Calls
1
5/5/14 –
10/16/14
10/17/14
10/27/1410/31/14
11/1/1412/31/14
2
10/17/1412/14/14
12/15/14
12/19/14
12/22/141/31/15
3
12/15/141/1/15
1/2/15
1/9/15
1/12/151/31/15
26
PROPRIETARY AND CONFIDENTIAL
Key Member Deliverables Cont’d
Communication
Description
Timing
MyAccount Updates
(supported by CVS) and Drug List
• Article in the secure portal creates
awareness of the program as well
as benefits available
• Specialty Drug List clarifies which
pharmacy to use by drug-class and
will be updated on CareFirst public
member site quarterly.
•
•
Secure sign-on article targeted for
11/30/14
Drug List Posted 8/12/14 (updated
quarterly)
Open Enrollment Education
1.Open Enrollment Book (Large
Group)
2.Open Enrollment Fliers on ordering
system for Sales and Brokers
• Used at benefit and health fairs
for members belonging to
groups larger than 200
members
• Brokers can use these fliers as
well for smaller groups
Updates to existing member-facing
materials used during open-enrollment:
• Creates awareness of Exclusive
Specialty Program
• Educates and outlines the benefits
and resources available to
members
Targeting 10/1/14
27
PROPRIETARY AND CONFIDENTIAL
Key Provider Deliverables
Communication
Exclusive Specialty Fax
Blast
Specialty Prescriber
Telephonic Outreach
Consultative Visit for Top
Specialty Drug Prescribers
Description
Timing
Communicate prescribing
physicians:
• CVS and/or OncoSource RX
will be exclusive provider
• Next steps and resources
available
• Include Exclusive Specialty
drug list
[Insert Timeline and Table if data-pull
and
phases
are required]
1
5/5/14 –
10/17/14
10/27/14-
Follow-up from fax blast:
• Verbally ensure physician
understands the fax blast
• Address any questions
3
[Insert
Timeline
12/15/14-and Table
1/2/15 if data-pull
1/9/15and
1/1/15
phases are required]
Top prescribing physicians will
have a personal 1x1 consultative
visit to :
• Walk-through the process
• Update any necessary
paperwork
• Answer any questions
Targeting November through December
Phase
Target
Range
Data Pull
Date
10/16/14
2
10/17/1412/14/14
Fax Blast
10/31/14
12/15/14
12/19/14
Telephoni
c
Outreach
11/1/1412/31/14
12/22/141/31/15
1/12/151/31/15
28
PROPRIETARY AND CONFIDENTIAL
Agenda
Overview of Specialty Marketplace
Specialty Pharmacy Coordination Program
CareFirst’s Exclusive Specialty Network
Communication Strategy
5 Implementation Timeline and Requirements
Appendix
29
PROPRIETARY AND CONFIDENTIAL
Exclusive Specialty Implementation Timeline
Only applies for those accounts/members with pharmacy benefit
Timeline
October 1, 2014
January 1, 2015 (CORE
turnkey)
CareFirst House Account Pilot
Fully Insured MD HMO and DC HMO and PPO
(ALL sizes)
100-199 FACETS Standard Non-Risk
January 1, 2015 Core Upon
Renewal
January 1, 2016 (CORE
turnkey)
200+ Non-Risk (ALL products, ALL
jurisdictions)
Fully Insured MD PPO
Virginia risk accounts are NOT eligible for Exclusive Specialty Pharmacy
based on state regulations
30
PROPRIETARY AND CONFIDENTIAL
Broker and Employer Constituent
Communications
Key Broker Objectives
Ability to articulate the value of the exclusive specialty pharmacy program
• Client-specific information/data enabling brokers to illustrate the value to our current
clients
31 studies or proof points for prospective clients
• Utilize case
Key Employer
Objectives
Awareness of exclusive specialty pharmacy program value
• Helping an employers manage their employees chronic conditions
• Address any client concerns
• Detail pharmacy care management services
31
PROPRIETARY AND CONFIDENTIAL
Review of Key Takeaways
•
•
•
•
What are Specialty medications and how are they driving pharmacy
costs?
How is Specialty Pharmacy Coordination (SPC) program differentiated in
the market?
How does Exclusive Specialty support SPC and why is it the most
appropriate delivery system?
How are SPC and Exclusive Specialty Network a proactive approach to
controlling overall health care spend?
32
PROPRIETARY AND CONFIDENTIAL
Agenda
Overview of Specialty Marketplace
Specialty Pharmacy Coordination Program
CareFirst’s Exclusive Specialty Network
Communication Strategy
Implementation Timeline and Requirements
6 Appendix
33
PROPRIETARY AND CONFIDENTIAL
Specialty Pharmacy Coordination Integrated Process
Engagement
Outreach*:
PBM and
Medical
Claims data
Identify patients
eligible for
specialty
pharmacy
coordination
program
Open Specialty Pharmacy
Network
Intro Letter
•Introduce program
*5 to 6 days post letter
Pharmacy Outreach:
CareFirst Exclusive
Specialty Pharmacy
Network
• Provide standard patient care
and schedule shipment
• Introduce program
• Obtain best time/day to call
CareTeam• Document introduction results
• Share results with SPC Nurse

Patient
Agreeable
Ongoing Clinical
Collaboration
Nurse Outreach/Inbound:
Data to CareFirst:
• Member engagement (Contacts; dates;
etc.)
• Disease Management Plan
• Encounters/assessments
• Alerts to Care Coordinators
• Supports Operations and Outcomes
Reporting
Data
CareFirst iCentric
Medical Health
Record
SPC Nurse
• Specialty Pharmacy Coordination
Nurse/CareFirst Nurse collaboration for
patients w/active CarePlan
• Nurse assesses patient for additional care
needs
– Care optimization
– Symptoms
– Specialty pharmacy
– Self-care
– Co-morbidities
• Monitoring criteria is condition and drug
specific
• Nurse refer to plan’s ancillary programs based
on need (behavioral health: Magellan, case
management: CareFirst, wellness: TBD)
34
PROPRIETARY AND CONFIDENTIAL
Basic Flow—Specialty Pharmacy Process
– Members will be welcomed via letter and phone call to let them know they must go to a
pharmacy in the CareFirst Specialty Exclusive Network
– If a member attempts to fill a specialty prescription outside the network, the pharmacy
will get a message guiding the member to call the dedicated CareFirst specialty phone
number
– If the need is urgent, an override can be entered to allow the fill
– Overrides should only be provided for emergency situations only
35
PROPRIETARY AND CONFIDENTIAL
Point of Sale Experience for Exclusive Specialty Pharmacy
Member Trying to Fill at Non-Network Pharmacy
Exclusive Specialty
Pharmacy member
tries to fill a specialty
medication at a nonnetwork specialty
pharmacy
Actual point of sale
reject message at
pharmacy directing calls
to CVS Caremark
Specialty Customer
Care:
“Product/Service not
Appropriate for This
Location Specialty Drug:
Call 855-264-3237”
For an urgent
need, an override
can be entered
through CVS
Caremark
Specialty
Customer Care
36
PROPRIETARY AND CONFIDENTIAL
CareFirst Specialty Pharmacy Drug List
37
PROPRIETARY AND CONFIDENTIAL