Is your pharmacy benefit manager delivering value?

If your pharmacy benefit manager isn’t actively adding value to your benefit plan, you’re not getting your money’s worth.

In pharmacy care services, the concept of value can mean many things. A pharmacy benefit manager can offer value with solutions that address the biggest drivers of trend or that offer protection from claims for rare but ultra-expensive medications. 

PBMs can offer value by:

• Providing strategic guidance to help you navigate the cost and complexity of pharmacy benefits
• Giving you the insights, guidance and tools to dig deeper into medication costs
• Offering you new choices to pay for them
• Creating a better-connected ecosystem where data moves seamlessly
• Giving doctors and members the tools they need to make better decisions and ease access to medications

Therefore, the question now becomes: Is my PBM keeping up? Are they giving me what I need to properly manage my prescription benefit costs?

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 even an entire drug class. 

The increased use of GLP-1 medications to treat diabetes has become a prominent driver of pharmacy trend. GLP-1s have also gained new indications for the prevention of cardiovascular events, sleep apnea, chronic kidney disease and, most notably, as a treatment for obesity.

As use of these medications surge, Optum Rx has capabilities to help you develop a GLP-1 approach that meets patient needs, balances cost and reflects organizational goals. Optum Rx Weight Engage drives appropriate utilization of GLP-1s by taking a holistic approach that maximizes their effective use. It also guides members toward improved health outcomes while controlling costs.

Another area where a dedicated strategy is essential to reducing spend is biologic drugs, especially in the anti-inflammatory class. Optum Rx was the first PBM to add a biosimilar option for Humira® to its formulary at parity with the original product. 

We offer plan sponsors a choice when it comes to biosimilars that includes both the high-list-price and the low-list-price options, as well as 2 biosimilars with up to $0 copay support for patients.

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. It also entails giving accessible, clear and verifiable information to physicians, pharmacists and members. 

One way we encourage transparency is through offering a choice when it comes to paying for therapies. These payment options include:

• Pass through
• Acquisition cost
• Reference-based and guarantee models 

Knowing which medicines end up on a formulary and why is another important aspect of transparency. Our Pharmacy and Therapeutics Committee is comprised of independent physicians, pharmacists and clinicians who review the relevant data and scientific literature for new medications to provide unbiased recommendations. Clients are welcome to observe as it deliberates and review its materials. 

To help you verify that you’re getting the full value of the pharmacy benefit, clients have access to multiple types of data for auditing, including:

• Manufacturer contracts
• Network contracts
• Acquisition cost audits

Our clinical consultants and formulary strategy advisors will also review formulary recommendations, logic and modeling with you. This allows you to make an informed decision that best aligns with the unique needs of your plan.

A continuously evolving mix of economics, technological improvements and consumer expectations can impact pharmacy benefits. We’re dedicated to partnering with you to help navigate this complexity. 

Few things exemplify the need for expert advice more than the regulatory landscape. Last year, approximately 650 new state and federal bills concerning how the pharmacy benefit is administered were proposed. Our External Affairs team closely monitors and acts to influence legislation and requirements that would impact our ability to control costs and serve you and is accessible through regular, interactive webinar sessions. 

To provide clinical expertise, we rely upon the combined experience of more than 10,000 pharmacists, pharmacy techs 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

Optum also invests in technology to provide you with strategic advice 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.

Of the thousands of therapies covered on a typical pharmacy benefit plan, some can have an outsized impact on your spending. 

Specialty Risk Protection

Although used by only a small percentage of patients, specialty drugs now make up half of all prescription drug spending. Specialty Risk Protection is an innovative strategy that provides an in-year guarantee for a plan’s specialty pharmacy spend. This approach helps limit volatility by managing use to address specialty trend on a year-over-year basis. 

Relatively rarer but even more expensive are gene therapies, which provide hope to people with certain genetic diseases. They are also the costliest medicines in history. The first gene therapy, Luxturna, was approved in 2017 to treat inherited retinal dystrophy, a rare, hereditary form of vision loss that impacts approximately 1,000 to 2,000 people in the U.S.⁴ Some recently approved gene therapies are treating relatively more common conditions, including sickle cell disease and hemophilia. For example, Lyfgenia, a gene therapy approved in 2023 for sickle cell disease, has a list price of $3.1 million per patient.⁵

Gene Therapy Risk Protection

As more gene therapies enter the market, the odds that a plan sponsor will incur a claim for one will likely rise. Optum Rx Gene Therapy Risk Protection helps plan sponsors manage this financial exposure. As a stop-loss insurance solution, this product safeguards against unexpected million-dollar treatments by spreading therapy costs into a predictable PMPM/PEPM fee.

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 drug is safe, effective and appropriate for the patient. 

Optum Rx PreCheck Prior Authorization

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 a prescribed medication at the pharmacy. 

Optum Rx Price Edge

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 insurance plan, eliminating the burden of searching themselves. 

Optum Savings IQ™

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. 

In 2024, Savings IQ helped eligible members save $1.3 billion on specialty medications and reduced the average out-of-pocket cost to $5.⁷

Partner with Optum Rx

Partnering with the right PBM is critical to controlling costs and improving health outcomes. At Optum Rx, we go beyond traditional pharmacy benefit management by delivering value through transparency, innovation and strategic guidance.

From managing specialty drug spend to leveraging advanced analytics and digital-first solutions, we help you stay ahead of pharmacy trends and achieve better results for your members.