Are you realizing the full value of your pharmacy partnership?

How CVS Pharmacy can help payers manage costs, improve quality and support better member health

Health care payers invest significant resources in formularies, benefit designs, utilization management and clinical programs intended to control costs and improve member health. Realizing the full value of those strategies depends on consistent execution at the moments when members make medication and health care decisions.

A few core moments can materially shape value across a covered population: starting and staying on an appropriate therapy; choosing a clinically appropriate, lower-cost alternative when available; identifying medication or other health risks before they contribute to emergency department visits or hospitalizations; and receiving recommended vaccinations before preventable illness leads to more costly care.

Individually and collectively, these can have a significant effect on pharmacy spend, medical utilization, quality performance and member health outcomes.

Payers already use benefit design, provider engagement and member outreach to encourage clinically appropriate, cost-effective care. An effective pharmacy partner can meaningfully reinforce these efforts at consequential points in the member journey: when a prescription is started, refilled or changed and when a member has questions about their health or faces barriers to treatment.

Each interaction creates an opportunity to translate payer strategy into action by supporting adherence, closing care gaps, encouraging clinically appropriate lower-cost alternatives and identifying medication risks. Pharmacists provide an accessible, ongoing touchpoint, while effective digital tools and patient-targeted outreach can extend support between visits and can help address barriers across different member populations and markets.

CVS Pharmacy® brings together market-leading patient access, millions of daily interactions, local pharmacist engagement, extensive digital tool and analytics support and dedicated clinical programs to help payers activate strategies consistently at scale. These capabilities also generate pharmacy and engagement insights that can help identify intervention opportunities, target member support and measure program performance.

Three ways pharmacy patient engagement can help create system-wide savings

At a glance, pharmacy engagement can create value in three ways: helping members stay on therapy, supporting lower-cost medication choices and identifying medication risks before they become more costly events.

1. Reaching members before an adherence gap becomes a health risk

For individuals managing chronic conditions, missing or discontinuing medication can affect both health outcomes and health care costs. The challenge for payers is identifying members at risk and reaching them with relevant support before a gap in therapy leads to a more serious health event.

CVS Pharmacy uses proprietary patient data and targeted engagement capabilities to support members who may be at risk of falling off therapy. CVS pharmacist and technician outreach through dedicated Centers of Excellence, personalized digital messaging, and local pharmacy team engagement help connect members with refill and adherence support when it is most relevant to impact behavior or help address issues that may be negatively impacting adherence.

For payers, this type of stronger adherence can help improve chronic-condition management and medication-related quality measures while decreasing costly downstream healthcare events. Recent peer-reviewed evidence across many different chronic-disease populations associates better adherence with fewer emergency department visits, hospitalizations and lower medical costs. 

For example, a 2024 American Heart Association study showed adherence >80% PDC to antihypertensive medication among commercially insured 18-64 year olds was associated with $1,441 lower total medical cost per year, 200 fewer emergency department visits per 1,000 patients, and 89.6 fewer inpatient admissions per 1,000 patients*. A pharmacy partner with effective adherence support at scale and across conditions and member types can be a key component of helping patients and payers realize these types of benefits. 

2. Helping members use lower-cost alternatives when available

Formularies and benefit designs can establish preferred therapies, but their financial value depends on whether clinically appropriate lower-cost options are consistently used.

Generic medications can provide clinically appropriate, more cost-effective alternatives to branded drugs, helping members and payers manage prescription costs.

CVS Pharmacy also supports formulary adoption through patient and provider outreach that helps inform them about potential clinically appropriate alternatives. In one formulary optimization program, outreach earned a 96% patient satisfaction rating; in another, a health plan achieved a 4-percentage-point lift in formulary compliance and $1,992 in average annual gross plan savings per targeted, updated prescription.*

Applied across a large patient population, consistent use of lower-cost and preferred alternatives can help payers strengthen formulary performance and reduce unnecessary pharmacy spend at the point of dispensing.

3. Identifying medication risks before they become costly events

Medication-related issues can create both clinical risk and avoidable cost. Potential interactions, duplicate therapies, inappropriate dosing and complex medication regimens may go unaddressed until they contribute to a more serious health event.

CVS Pharmacy uses technology-enabled drug utilization reviews (Smart DUR) and specially trained pharmacist-led clinical programs to proactively screen patient’s prescriptions and identify opportunities for intervention.

CVS Pharmacy also conducts Comprehensive Medication Reviews on behalf of payers – leveraging the CVS #1 healthcare brand reputation among consumers* and geographically distributed local pharmacist outreach - to help uncover potential medication-related problems, improve members’ understanding of their therapies and identify opportunities to make medication use safer and more effective.

Identifying and addressing these concerns before complications arise can help payers support safer patient medication use and potentially avoid unnecessary downstream utilization.

Extending pharmacy engagement beyond the prescription

The financial impact of pharmacy engagement can extend well beyond the prescription itself.

When members receive appropriate medications, remain engaged in therapy and avoid disruptions in treatment, payers may see benefits across the health care system. Better medication use and clinical support can support improved management of chronic conditions, stronger quality performance and reduced total cost of care.

Exploring the potential impact on emergency department utilization

Emergency department utilization is an important driver of medical spend. In an observational analysis of members of a large national health plan who filled three or more retail prescriptions, members using CVS Pharmacy had approximately 6% fewer emergency room visits than members using competitor pharmacies and approximately 12% fewer visits than members using multiple pharmacies.* Note: findings showed a statistically significant association within the analyzed population, but do not establish that pharmacy choice alone caused the difference.

To illustrate the related scale of potential cost management impact, applying a separate benchmark of approximately 193 emergency department visits per 1,000 members to a hypothetical plan covering 10 million lives yields roughly 1.9 million annual visits. Applying the analysis’s upper-bound 12% association and an estimated average payer cost of approximately $3,250 per visit would equate to about 232,000 fewer visits and more than $750 million in potential avoided medical costs.*

The example underscores why pharmacy support should be evaluated beyond the pharmacy claim while keeping actual program results distinct from observational findings and modeled scenarios. The broader opportunity is to use timely pharmacy engagement to support better medication use and help address avoidable utilization and total cost of care.

Preventing costly illness through immunization

Pharmacy engagement can also create value by helping members receive recommended preventive care before illness results in more complex or costly treatment.

CVS Pharmacy provides payers with a scalable channel for immunization outreach, education, scheduling and administration. Its broad community presence and digital plus education engagement help make vaccinations easier for members to access,  while supporting payer efforts to close preventive care gaps.

Supporting quality performance and plan value

The value of pharmacy engagement is not limited to direct cost avoidance. Pharmacist-led refill outreach, medication counseling, immunization support and medication reviews can also contribute to measures that affect quality performance.

According to a Pharmacy Quality Solutions analysis, CVS Pharmacy ranked #1 in Medicare medication adherence performance for total member support across hypertension, cholesterol and diabetes measures.*

For Medicare plan sponsors, these measures can contribute to overall Star Ratings and support performance tied to quality bonus eligibility, plan competitiveness and broader business objectives. CVS Pharmacy adherence solutions have helped a major national health plan achieve higher Medicare Star performance through positive influence on adherence measures for hypertension, cholesterol and diabetes.*

The result is value that reaches across multiple payer priorities: better member support, stronger quality performance and improved financial outcomes.

Realizing more value through closer pharmacy partnership

Contract economics are one component of pharmacy cost management. The broader opportunity is to use pharmacy engagement to translate payer strategies into action and create value across pharmacy and medical spend.

When payers collaborate closely with pharmacy partners, they create more opportunities to support adherence, encourage cost-effective medication use, close preventive care gaps and address health risks before they lead to more costly care.

CVS Pharmacy combines broad community access, millions of patient interactions, digital tools, targeted outreach and pharmacist-led clinical programs to help payers execute consistently across populations and markets. Integrated pharmacy and engagement data can further help identify intervention opportunities and measure program effectiveness, subject to applicable data availability, permissions and program design.

The right pharmacy partnership does more than fill prescriptions or communicate benefits. It gives payers a scalable way to activate strategy at the point of care, engage members through accessible pharmacists and digital channels, and evaluate measurable results across pharmacy quality, medical utilization and member health.

What could greater pharmacy value mean for your population?

Connect with CVS Pharmacy to explore how targeted member engagement, pharmacist-led clinical support and population-level interventions can help advance your cost-management, quality and member health objectives.

Connect with CVS Pharmacy