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Optum Rx Reduces Over 10% of Overall Pharmacy Prior Authorizations, Impacting Dozens of Drugs
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Key Takeaways
- Optum Rx reduces reauthorizations for 80 medications, addressing criticisms of prior authorization processes and improving patient access to medications.
- The policy change could influence other PBMs, amid growing dissatisfaction and legal actions against PBM practices.
The announcement could ease the burden of prior authorizations on patients, which can cause unnecessary delays for patients receiving prescriptions and serious complications.
Optum Rx, the pharmacy benefit manager (PBM) of UnitedHealth Group Inc., has announced in a news release that it is reducing up to 25% of reauthorizations, comprising over 10% of overall pharmacy prior authorizations, for a list of 80 medicines that will be expanded over time through collaboration with pharmacists and other treatment providers. The policy change is a significant development for patients and their providers, who have in recent years increased their criticism of prior authorization, claiming it produces avoidable harm and waste.1,2
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The drugs covered in this new policy include those indicated for migraine, multiple sclerosis, cystic fibrosis, pulmonary arterial hypertension, idiopathic pulmonary fibrosis, and cholesterol. The list of included medicines features inclisiran (Leqvio; Novartis), evolocumab (Repatha; Amgen), ofatumumab (Kesimpta; Novartis), atogepant (Qulipta; Abbvie), and numerous others covering the included indications.1,3
In the news release, Patrick Conway, MD, CEO of Optum Rx, said that the company was “taking meaningful steps to simplify patient experiences and increase access to critical medications.” Conway explained how the changes are intended to provide “easier access to medications for consumers” and “less work for pharmacists and physicians.”1
Prior authorization is used by insurance companies to help rein in costs. Through this process, physicians are often required to get approval from an insurance company before they agree to pay for the cost of a patient’s drugs, even if a patient has already been using the drug. The process can be arduous, burdensome, and sometimes even dangerous for patients, despite the historical claims from PBMs being that the process helps preserve quality and control the cost of drugs.2,4
In a survey conducted by the American Medical Association (AMA), over 4 in 5 physicians reported that prior authorization led to increased use of health care resources. Most concerningly, two-thirds of physicians said that the process led to resources being diverted to ineffective initial treatments or additional office visits, and about half responded that prior authorization requirements were associated with urgent or emergency patient care.2
“Health plans continue to inappropriately impose bureaucratic prior authorization policies that conflict with evidence-based clinical practices, waste vital resources, jeopardize quality care, and harm patients,” Jack Resneck Jr., MD, president of the AMA, said in a statement accompanying the survey results. The survey results indicate that there is an across-the-board dissatisfaction with the prior authorization process among pharmacists and physicians, with broad indications of bad outcomes, delayed or disrupted care, and patient harm. Optum Rx’s announcement could open the floodgates for similar policy changes among other PBMs, relieving the pressure that builds up on care providers when prior authorization requests burden care.1,2
There has been increasing dissatisfaction with the practices of PBMs in recent years. The Federal Trade Commission (FTC) recently filed suit against 3 of the biggest PBMs, including Optum Rx, for allegedly unfair business practices that have driven up costs of critical drugs for patients and generated massive profits for themselves. The FTC has targeted rebates that these companies pay to acquire specific drugs on a list of covered medications, claiming that these rebates inflate the cost of drugs. Besides legal action, there is bipartisan pressure building on PBMs in the form of legislation that could reshape their business practices.5
For pharmacists, Optum Rx’s change in prior authorization policy could pay dividends, not only in the form of speedier and more optimized prescribing but also in improved patient outcomes. Whether or not a patient receives a drug covered by their insurance in a timely manner could mean the difference between a positive disease recovery or a serious adverse complication. Pharmacists can play a crucial role in counseling patients covered with Optum Rx on if treatments they were prescribed are included in the Optum Rx’s new program. Furthermore, they should be keenly aware of any expansions to the current list of drugs that no longer require reauthorization and update patients as necessary.
