5 questions executives are asking about AI in pharmacy benefits

Optum Assistant — an AI-powered digital companion — will transform the way members interact with their health benefits and pharmacy care. Through a natural, conversational experience, members can:

• Check coverage
• Identify savings
• Ask prescription questions
• Complete member requests

Optum Assistant is a member-facing interface that sits on top of our overall AI ecosystem. So, rather than navigating multiple portals or complex menus, members can simply ask Optum Assistant for what they need. It will understand intent, guide members to the right information and connect them to appropriate support — whether automated services or a human advocate — creating a more seamless and personalized experience. 

Our AI-based predictive analytics capability is transforming member engagement by anticipating member needs for faster, more seamless support. We make sure members feel supported and understood through a combination of automation and ‘human-in-the-loop’ logic. So while our member chat experience can now automatically predict more member intentions, when the chatbot is unable to address their needs, the members are automatically routed to a live digital chat agent.

Our approach prioritizes human control. AI supports — but never replaces — critical human decision-making. There’s always a clinician or advocate in the loop to make the right call for members and patients.

Our responsible AI practices ensure that AI is designed and used fairly, ethically and safely. Our Responsible AI Guiding Principles provide the foundation for all AI work conducted across the enterprise. These principles include:⁴

• Reliability & quality
• Fairness
• Accountability
• Transparency
• Privacy & security
• Continuous improvement

Our Responsible AI program enables us to consider, identify and address potential risks that could impact our members, patients and customers  before they happen. These steps help ensure we implement our tools fairly, accurately and securely.

Fraud, waste and abuse can include unintentional issues, such as duplicate therapy or unnecessary refills. Less commonly, fraud can be intentional actions like overbilling, billing for brand drugs while dispensing generics or prescription forgery.

Our AI-enabled analytics spot potential fraud, waste and abuse in real time and retroactively. AI flags unusual patterns sooner and highlights characteristics common to fraud, waste and abuse. This approach helps auditors focus on the highest-risk activity to protect clients and increase patient safety.

One example of a capability on our AI roadmap is agentic AI. This  newer approach to AI can be used to identify patterns in data and generate actionable recommendations. Optum Rx is using agentic AI to tackle one of the most complex challenges in pharmacy: predicting client trend.

We're developing a trend diagnostic tool that uses agentic AI and analyzes diagnostic metrics to forecast and model trend to help plan sponsors better understand their future spending on pharmacy benefits.

As AI continues to evolve, Optum Rx remains committed to responsible innovation and creating a future where AI empowers people, delivers answers faster and augments human decision-making.

When it comes to pharmacy benefit management, the difference between a vendor and a true partner is everything. Our platform combines enterprise-scale performance with intelligent AI solutions embedded across the experience.

From predictive member support to real-time provider tools and client trend analytics, we’re delivering impact where it matters most. And we’re always advancing — engineered to transform the future of pharmacy benefits with smarter, safer and more connected care