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Advanced Utilization Management Program

Business people sitting at table looking over paperwork

With new drugs launching every month, the pharmaceutical pipeline is robust and the marketplace is constantly evolving. A large portion of these drugs are expensive therapies that will typically be considered specialty medications once approved by the U.S. Food and Drug Administration. Specialty medications will trigger automatic utilization management (UM) programs for our member groups aligned with the CVS Caremark specialty medication formulary. It is crucial to highlight potential management opportunities for these novel, high-cost drugs not already managed by CVS Caremark’s Specialty Guideline Management program.

National CooperativeRx Response

In addition to the numerous clinical programs we already offer our members, National CooperativeRx will implement a new program in 2021 that will focus on automatic UM updates in response to these ever-changing marketplace dynamics.

Our on-staff pharmacists will ensure the UM tools applied, such as prior authorizations, quantity limitations, or step therapy requirements, are fundamentally sound and clinically appropriate. We anticipate minimal plan impact and will provide a 30-day notice to members who may encounter the new UM tools.

Advanced UM Program Details

National CooperativeRx monitors the pharmaceutical marketplace for new therapies in the pipeline. The new Advanced UM program simply offers our member groups an opportunity to employ our recommendations in a timelier manner to better adapt their plans to the rapidly changing market. Our initial round of updates will focus on the management of:



digestive health medications


anti-viral medications

continuous blood glucose monitors

These categories were all targeted based on product prices, potential impact, and recent marketplace changes.

Our ongoing focus on thoughtful clinical management is one aspect that distinguishes the Cooperative from other pharmacy benefit manager arrangements. We believe our membership trend helps illustrate the success of our clinical approach and independent expertise, which we look to build upon with this program.

Please be on the lookout for information next week on enrolling in our new Advanced UM program that will launch April 2021. If you have any questions in the meantime, contact your National CooperativeRx account executive.

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