Multifaceted specialty pharmacy strategy goes beyond the basics

July 20, 2022 | Download PDF

CarelonRx recognizes that when it comes to specialty drugs, you need an approach that centers on member care while balancing the growing costs of specialty medications. We’re focused on delivering a comprehensive strategy that takes a holistic approach to whole health, member advocacy, and cost management.

Studies show members who take specialty medications are a small percentage of an employer’s overall population, however, specialty drugs account for 59% of total drug spend.1 So how do you manage constantly rising specialty drug costs? First, you start at the foundation: whole health.

Reinventing the personalized care experience

Our clinical management is built on evidence-based drug lists. Our Pharmacy and Therapeutics committee works collaboratively to align drug choices that are effective and cost efficient. Our robust prior authorization strategies, supported by evidence-based treatment guidelines, require documentation from providers to ensure the appropriate labs, diagnoses, and treatment paths are being adhered to.

Members enrolled in our Specialty Condition Management program are contacted by a nurse to help walk them through their specific condition care goals and treatments, giving them a personalized, whole-person approach to their health including addressing additional medical issues or comorbidities such as diabetes or hypertension.

This program covers 21 specialty conditions, from hemophilia to multiple sclerosis to Crohn’s disease. A dedicated nurse now acts as a liaison between the member and the provider by coordinating with the provider to address opportunities in specialty care and ensure that the value-based incentives are aligned to meet quality and cost of care goals.

Ensuring incentives align with providers for our CarelonRx members is a critical component to our whole health approach and helps manage the overall growing specialty trends.

Incorporating the digital touchpoints

In addition to providing a personalized member care experience, CarelonRx is using digital solutions to meet members where they are. One way we’re addressing specialty condition management is through our concierge care app. The app is designed for self-led care and support. Using the app, members can instantly connect with care resources, such as nurses who can answer their questions about medication side effects, offer nutritional advice, activate medication reminders, and find appropriate referrals. By offering easily accessible member support and resources, members don’t have to go through their health challenges alone.

CarelonRx recognizes that members need support and care in the moment, and that often happens outside traditional office hours. We have found that more than half of member symptom reporting and chat requests take place after hours. The concierge care app offers that direct touchpoint and by doing so, can help reduce the risk of ER visits and hospitalizations.

Tools and programs to combat the growing cost of specialty pharmacy

The final piece of CarelonRx’s whole health approach addresses one of the most complex challenges of specialty drug management facing members and employers today cost management. We believe our whole health approach to high-cost claim management can effectively change member behavior, improving health and ultimately driving down costs.

Our enhancements start by improving our high-cost claimant reporting for employers and consultants. We make it easier to identify high-cost members and what is driving those high costs through our RxGuide solution. In addition, we are adding in predictive analytics to help identify which members might have high-cost claims in the future.

Our concierge style targeted interventions are another strategic tool we use for high-cost claimants. By designing high-touch pharmacist-led interventions, we can address everything from site of care management and missed dose opportunities, to appropriate drug alternatives. Programs like these play a significant role in helping manage drug spend.

Balancing care management with cost management

Another way we’re combating the growing cost of specialty drugs is through our Cost Relief program. This program allows members to get virtually all specialty medications with no out-of-pocket cost. The program works by maximizing copay assistance dollars available from manufacturers for specialty drugs, taking the guess work out of copay costs. Members enrolled in the program will have a $0 out-of-pocket cost even if no manufacturer assistance dollars are available for their Cost Relief eligible drug. The Cost Relief program includes high-touch enrollment support and outreach by specialists who manage and coordinate complex and expensive specialty medications.

The program also helps CarelonRx clients save money. The copay assistance dollars available are also used to reduce employers’ costs for specialty medications, resulting in a typical savings of up to 25% of total specialty drug spend.2 At CarelonRx, we believe cost management has to be balanced with ensuring members have access to the right drug at the right time, to help improve quality of life.

Our unique approach of combining our Specialty Condition Management program, provider partnerships, digital touchpoints, and cost savings programs allows us to give members the support and care they need, while ensuring they have access to the medications they require.

A comprehensive approach to whole person care, with a goal of improving their whole member health is at the foundation of everything we do.

Learn more about CarelonRx’s multifaceted specialty pharmacy strategy that goes beyond the basics by watching this video session.


1. IngenioRx, 2020 Drug Trend Report (July 2021)

2. Based on our BOB claims data for copay plans, 2021.

NOTE: Exclusive Specialty Pharmacy and Specialty Drug Accumulator Rules are required for Incorporating the digital touchpoints