Is your PBM delivering the best value? 4 key questions to ask

With new high-cost medications constantly coming to market, pharmacy trend is inherently dynamic. PBMs need to see over the horizon to identify the trends that can impact spending. They also need to be agile enough to offer solutions to help you manage these new sources of spending, whether it’s a newly approved medication or an entire drug class.

The increased use of GLP-1 medications has become a prominent driver of pharmacy trend. In addition to their longtime use for diabetes, GLP-1s have also gained indications for the prevention of cardiovascular events, sleep apnea, chronic kidney disease and, most notably, as a treatment for obesity. As use of GLP-1 medications grows, Optum Rx® has introduced capabilities to help you develop a dedicated coverage approach.

Optum Rx Weight Engage supports appropriate use of GLP-1s by taking a holistic approach that maximizes their effectiveness. It also guides members toward improved health outcomes while controlling costs.

Another area where a dedicated strategy is essential to reducing spend is biologic medications. This is especially true in the anti-inflammatory class where biosimilar options to branded medications, such as Humira® and Stelara®, have become available. Optum® Rx was the first PBM to add a biosimilar option for Humira® to formulary at parity with the original product. As more biosimilars come to market, Optum Rx offers plan sponsors choices so they can make decisions that meet patient needs while balancing costs and organizational goals.  

True transparency in pharmacy benefits means having insight into all the processes and data necessary to understand how your pharmacy benefit dollars are being spent. We have been expanding transparency for years by making financial flows independently auditable and providing greater visibility into rebate economics and formulary decisions through our independent Pharmacy & Therapeutics Committee. We have also committed to passing through 100% of manufacturer rebates by January 1, 2028.

Optum Rx recently unveiled a new transparent pharmacy care model that fundamentally changes how pharmacy benefits are priced and delivered. The new model features a monthly fee-based structure that is independent of manufacturers’ list prices or prescription volume, eliminating spread pricing to deliver greater clarity and affordability to pharmacy care. This simple and stable pricing structure helps plan sponsors improve predictability when budgeting pharmacy costs.

The new model is paired with new digital tools that give consumers upfront visibility into what their prescription will cost. Knowing pricing information prior to filling a prescription enables members to make cost-conscious decisions, reducing surprises and improving adherence at the point of care.

A continuously evolving mix of clinical, regulatory and technological factors can impact pharmacy benefits. We’re dedicated to partnering with you to help navigate this complexity.

To provide clinical expertise, we rely upon the combined experience of more than 10,000 pharmacists, pharmacy technicians and clinicians. They gain actionable insights from your clinical data to better understand potential risks and identify the unique mix of solutions needed for you to achieve maximum cost savings and improved patient outcomes.

For example, highly managed clients that have our Premium Formulary, Comprehensive Utilization Management and Vigilant Drug Program in place see significant savings from weight loss medications, spending 36% less on GLP-1 medications.²

Guidance is also essential given the rapidly evolving regulatory landscape. Each year, hundreds of bills concerning how the pharmacy benefit is administered get proposed in state legislature. Moreover, federal actions are increasingly impacting pharmacy benefits as the government looks to lower medication costs through direct negotiation with drug makers. Our External Affairs team monitors and responds as needed to legislation and requirements that would impact our ability to control costs and serve you. The team provides you with timely updates through regular, interactive webinar sessions.

Optum also invests in technology to provide you with strategic advice that’s tailored to your specific data, needs and goals. Our latest innovation is Optum Rx Benefit Central™, a self-service portal for plan management that offers customized data and analytics. Featuring a user-friendly design and leveraging real-time data, Benefit Central provides you with the detailed insights needed to make informed decisions and stay ahead of potential issues.  

Eliminating data silos between stakeholders is fundamental to a frictionless pharmacy benefit. For greater simplicity, connectivity and transparency, we continue to invest in digital-first capabilities for prescribers and consumers.

Prior authorization (PA) ensures a prescribed medication is safe, effective and appropriate for the patient. Optum Rx PreCheck Prior Authorization (PreCheck PA) is a first-to-market innovation that uses our industry-leading data and analytics to prepopulate answers to clinical requirements for physicians seeking a PA. If all clinical criteria are met, PreCheck PA will grant approval within seconds. This avoids a patient being denied prescribed medication at the pharmacy counter.

Equally transformative is our price comparison tool called Optum Rx Price Edge. It provides members with a seamless experience by giving them instant visibility into the lowest available cost for their prescription. Price Edge automatically compares available direct-to-consumer prices with what the member would pay under their health plan, eliminating the burden of searching themselves.

Optum Savings IQ® is another cutting-edge solution that simplifies access to expensive specialty medications. It automatically aggregates financial assistance opportunities to match eligible Optum Specialty patients with resources and programs. For assisted members, Savings IQ enables more than $2,500 in average annual savings on specialty medications.⁴