How AI is powering new pharmacy innovations

Initial use cases included using a type of AI known as machine learning to create predictive models. These models leverage the ability of AI to recognize patterns in data. One area where this is immediately helpful is medication adherence. Models can help predict when a person becomes non-adherent to a medicine they are prescribed. This is especially important when treating chronic illnesses like diabetes, depression, or high blood pressure, where medication adherence helps prevent future medical costs related to the condition. 

Another area where AI exhibited immediate benefits is detecting suspicious patterns of behaviors in data to catch instances of fraud, waste, and abuse.  In the following years, new use cases continued to emerge. “We are really trying to drive the benefits of AI, whether they be member experience or efficiency opportunities, into all of our strategic areas,” Abraham says.

As the technology has matured, three broad categories of AI use at Optum Rx have become prevalent: predictive, generative, and agentic. 

• Predictive AI: Using past patterns to anticipate what comes next, we’re creating AI models that can predict the issues members might encounter related to their pharmacy benefits. Importantly, this use of AI empowers Optum Rx to address potential friction points proactively before members are even aware that an issue exists.
• Generative AI: This type of AI helps us utilize context to generate new content. One current use is in the creation of conversational agents that employ advanced natural language processing to understand and respond to member inquiries in real-time, providing personalized and accurate assistance. By automating routine tasks, generative AI can free up human agents to handle more complex issues while lowering response times and increasing member satisfaction. 
• Agentic AI: This newer approach to AI combines the flexibility of large language models (LLMs) with the precision of traditional programming 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 more than 2,500 diagnostic metrics to forecast and model trend to help plan sponsors better understand their future spending on pharmacy benefits. 

Ensuring responsible use of AI is paramount at Optum Rx. The private nature of medical and prescription drug data only highlights the need for responsible AI practices, Abraham says. “Healthcare data is highly sensitive and making sure that we provide the right safeguards to ensure that we are ultimately compliant with all elements of data security is priority one.”

He notes that our commitment to responsible AI includes governance models that ensure compliance with laws and regulations. In addition, he notes all AI use cases at Optum Rx are reviewed by a formal governance board to assess models for fairness, accountability, transparency, privacy, and security. 

“Human oversight is important,” Abraham says. “We call it ‘human in the middle.’ This makes sure that our AI models are supported by the appropriate guardrails and that decisions are ultimately made by the appropriate experts in any given area.”  

The need to temper the excitement around AI with a disciplined and measured approach is essential to creating useful AI-infused solutions, says Sid Sahni, Senior Vice President of Strategy and Innovation at Optum Rx.

“It really starts with the use case,” he says. “What is the problem we are trying to solve? What is the benefit that we are trying to derive?  And once you solve for that, you can then ask, where can AI assist? How could AI do this better?”

Sahni says use of AI has not only improved existing Optum Rx solutions in areas such as fraud, waste, and abuse detection and customer service but has also led to new innovations that might not have otherwise been considered. He cites the use of AI in call centers as a primary example.

“We've already use AI to better serve our members in our call centers, to predict what the member is calling about,” he says. “We can also use AI-powered ambient listening to actually understand and document what’s being said. Then at the end of the call we can use generative AI to create a summary of the conversation for the individual to review. This drives satisfaction and improves their experiences.”

Sahni is even more bullish about the future impacts of AI on pharmacy care services, adding that the underlying technology is still emerging.

He says Optum Rx is increasingly using AI to power member self-service and is already on a journey to an AI-enabled personalized member companion to answer questions and help members effortlessly navigate their pharmacy benefits. Looking further ahead, he notes that the potential of AI has been compared to the dawn of the industrial revolution. 

“Could AI represent that level of generational change in our industry and our society at large?  Of course, we need to think about this very responsibly and be aware of the risks. But at the same time, we want to be excited about the future and all the potential that AI can deliver for us. I don't think we fully comprehend it yet. This space is moving fast and we are moving with it. But as we go through, we will uncover things and learn things and think of things that are beyond our comprehension at this point.”

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

To learn more about how Optum Rx is using AI to improve pharmacy benefits, talk to your Optum Rx partner.  You can also listen to Santiago and Sid discuss the past, present and future of AI on a recent episode of the Pharmacy Insights podcast.