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2023 Cooperative Pricing and Management Enhancements

In 2022, National CooperativeRx secured an industry-leading three-year contract with CVS Caremark (CVSC). Our contract negotiations focused on best-in-class pricing, rebates, and contract language. 2023 pricing enhancements, as a result of these negotiations, total 4.2%. With 2023 best-in-class pricing already in hand, we focused our 2023 market check efforts on managing pharmacy spend and enhancing customer service.

National CooperativeRx is pleased to announce the addition of specialty medication prior authorization services and enhanced psoriasis management.

Specialty Medication Prior Authorization

January 1, 2023, National CooperativeRx onsite pharmacists and technicians will work alongside the CVSC systems to perform prior authorizations for all specialty medications. We will ensure the CVSC clinical criteria for approval are fully executed and, most of all, ensure the decision to authorize treatment makes sense clinically. Similar to the current CVSC process, National CooperativeRx will contract with an outside independent review organization to provide additional expertise as needed. Any calls regarding prior authorizations that are received by CVSC will be transferred to National CooperativeRx. Prior authorization appeals will be reviewed by a committee established by National CooperativeRx that will consist of a minimum of a medical director and four pharmacists.

Moving the prior authorization of specialty medications from the PBM to the Cooperative ensures our members receive the most appropriate treatment for their condition. We prefer to have this function carved out to ensure the PBM is not incentivized for additional drug spend. Our focused team of independent, non-biased clinical experts will review and coordinate treatment with providers and request documentation/medical record information when appropriate.

Our experience with non-specialty–and later specialty—high-dollar claims reviews for the past five years has made it clear to us that specialty medication prior authorization is a logical progression that will bring meaningful value to our membership. Specialty medication spend exceeds non-specialty spend for many of our Cooperative members. Specialty medication prior authorization services will be provided at no cost to our members. Further, we conservatively estimate $3.5 – $5 million in savings across the Cooperative from specialty medication prior authorization alone.

We are confident we can improve the specialty medication prior authorization process and provide a higher level of service, efficiency, and fairness to our clients and members.

Psoriasis Management

Our focus on specialty management does not stop with prior authorizations. In 2023, we will implement enhanced criteria to better manage psoriasis therapies for our members. Through the Cooperative-led specialty high-dollar review programs, the Cooperative identified psoriasis as a growing area of focus. Last year, the Cooperative spent $32 million on psoriasis therapies. In addition, experts estimate psoriasis spend will increase by 40% over the next five years. As part of the 2023 market check, enhanced controls over psoriasis spend are being built in at no additional cost to members and are expected to result in cost avoidance exceeding $2 million across the Cooperative.

We are excited to continue providing a personal, high-touch customer service experience to our members. We believe the enhanced 2023 pricing, specialty medication prior authorization services, and enhanced psoriasis management will allow us to deliver the best combination of services to manage pharmacy spend. These enhancements will circumvent industry games and provide patients with higher-value care. Our five-year 5.3% aggregate increase in per person pharmacy spend proves the value we continue to provide our members through prescription drug trend management.

Members do not need to take any steps to operationalize either program. If any members would like to make plan changes for 1/1/23, please reach out to your National CooperativeRx representative.

Learn about our prior authorization coordinator and clinical experts here.

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