Healthcare Finance: Optum Rx announces a reduction in drug prior authorization

Initiative will eliminate up to 25% of all reauthorizations, or 10% of overall prior authorizations, PBM says.

Optum Rx has announced it will drop prior authorization for an estimated 80 drugs starting May 1. 

The program targets reauthorizations of drugs. For instance, once a genetic condition such as cystic fibrosis is confirmed through testing, there is minimal additional value in reauthorizing an effective, lifelong treatment, said Optum Rx. 

The list of drugs is expected to be expanded over time.

WHY THIS MATTERS

This initiative will eliminate up to 25% of all reauthorizations, or 10% of overall prior authorizations, Optum Rx said.
 
"Optum Rx is taking meaningful steps to simplify patient experiences and increase access to critical medications," said Dr. Patrick Conway, CEO, Optum Rx. "These changes mean easier access to medications for consumers, less work for pharmacists and physicians, and a simplified system focused on clinical quality." 

Some reauthorizations are necessary for drugs that have safety concerns, need ongoing monitoring for dose adjustments, require additional tests or may have alternative therapy considerations, according to UnitedHealthcare's pharmacy benefit manager. 

For example, new drugs developed for Alzheimer's disease carry risks for the brain, and long-term effectiveness is not clear, the company said. For these treatments, ongoing review is important for patients, payers and physicians, it said.

In February 2023, Optum announced that two new medications were in the drug pipeline for Alzheimer's disease, Lecanemab and Donanemab. The FDA granted traditional approval to Leqembi, and in June 2023, the Centers for Medicare and Medicaid Services rolled out a plan to cover new Alzheimer's drugs when a physician and clinical team participates in a registry. The cost for Leqembi was estimated at around $26,500 per year.

Optum Rx also said it would continue to fight high drug prices set by pharmaceutical companies through both negotiation and cost-cutting tools.

Other savings programs touted by Optum Rx include:

• Optum Savings IQ, which matches eligible Optum Specialty patients with financial resources to lower their out-of-pocket costs. In 2024, the programs helped eligible consumers save $1.3 billion and reduced the average out-of-pocket cost to $5, according to OptumRx. 
• A Critical Drug Affordability List caps out-of-pocket costs for people on over 290 medications. Consumers pay $18 per month on average for insulin and typically $5 or less for most drugs, Optum Rx said. 
• Price Edge is a digital price comparison tool that has generated $224 million in consumer savings, with an average savings of $50 per consumer, Optum Rx said. 
• PreCheck MyScript automatically scans drug prices to provide real-time price information, generating consumer savings of $119 per prescription fill and client savings of $266. 
• Proactive Savings Alerts notifies consumers of savings opportunities averaging $42 per prescription. 
• MyScript Finder, which averages $58 in savings when used, enables consumers to see the price of their prescribed medication and gives information on alternative pharmacies and medications. 

THE LARGER TREND

UnitedHealthcare faced a backlash of anger over prior authorizations and claim denials after its CEO Brian Thompson was fatally shot Dec. 4 as he walked to an investors conference in Manhattan.

Suspect Luigi Mangione faces a first-degree murder charge.

UnitedHealth Group CEO Andrew Witty addressed the vitriol against the company in an op-ed published in The New York Times in late December 2024.

"We know the health system does not work as well as it should, and we understand people's frustrations with it. No one would design a system like the one we have. And no one did. It's a patchwork built over decades. Our mission is to help make it work better," Witty wrote, adding that the nation's largest insurer, UnitedHealthcare, was willing to partner with healthcare providers, employers, patients, pharmaceutical companies, governments and others to find ways to deliver high-quality care and lower costs.