New pharmacy benefit solutions to help bend the cost curve

The array of challenges faced by sponsors of the pharmacy benefit are constantly evolving. To help plan sponsors get a sense of the emerging options available to help them, host Scott Draeger from Optum Rx welcomed leaders of innovation and strategy, Mike McGinnity and Sid Sahni, to discuss the current state of innovation in pharmacy care services on the latest episode of the Pharmacy Insights Podcast.

Read on for edited excerpts of their conversation or listen to the full podcast episode.

Scott: One of the trends we're hearing a lot about in the marketplace and that's the need for transparency. Mike, can you tell us how Optum Rx approaches this?

Mike: Transparency is an important and often misrepresented or misunderstood subject in our marketplace.

Given the fiduciary responsibilities of plan benefit sponsors, it's important for us to equip and enable our clients with the data and information they need to uphold their obligations. At its essence, transparency is about access to information. This includes information for all stakeholders within the pharmacy benefit ecosystem, including members, pharmacies, providers, clients and consultants.

For our clients and consultants, transparency is access to our independent Pharmacy & Therapeutics (P&T) Committee, allowing them to see the decisions we make about which drugs should be on, could be on, or should not be on a formulary. They have full audit rates, so all of the terms and conditions within our contracts can be validated through independent third parties.

For our members, transparency includes access to all sorts of information through the client portals, including which drugs are covered and the price of the covered drugs. Does their drug require prior authorization and what are those requirements, and can they initiate it? It includes knowing which pharmacies they can go to, and which pharmacies offer them the best deal.

We provide them with all this information online and guide them around things such as copay cards. So, if there are manufacturers sponsored ways for them to reduce their out-of-pocket costs, they can get that information as well.

For our providers, one way we provide them with transparency is through PreCheck My Script (PCMS), which gives them formulary and utilization management information right in their workflow. It provides real-time cost information and covered medications. This information is similar to what members would see in the portal. It shows if a prior authorization is required and it can be initiated immediately through the electronic prior authorization system. It also lists clinically appropriate alternatives to a given drug, so a provider can choose to prescribe a different therapy that doesn't require prior authorization and circumvent that entire process.

Scott: Sid, could you follow up and add if there are any new transparency solutions plan sponsors should be aware of?

Sid: A commitment to transparency is not new or transient at Optum Rx. It is the core of how we choose to operate the next step in our ongoing commitment.nxiety and depression continue.

Scott: Outside of transparency, the topic that seems to be coming up quite a bit now is GLP-1 medications, which are primarily used to treat diabetes and obesity. Mike, what are the macro trends surrounding this drug class and are there any specific pain points that plan sponsors are facing that are spurring the need for innovation here?

Mike: Yeah, there sure are. Our clients need help to ensure they're providing access to critical medications for the members, but they also need guardrails to promote proper use.

Today we see that 77% of the traditional drug trend is being driven by these GLP-1s and they are accounting for 42% of the overall trend. More than half of US adults are already eligible for these products. In addition to diabetes and obesity, these drugs are gaining new indications for such things as sleep apnea, heart failure and chronic kidney disease. We have clients that need help deciding what they should cover, for whom and with what protections and parameters.

Scott: Sid, what can plan sponsors do about this today and how is Optum Rx helping clients navigate this critical space?

Sid: As Mike indicated, the key challenge surrounding GLP-1 medications is that the list prices set by pharma are just too high, especially for a drug class that has such broad use. That’s why we negotiate with manufacturers to bring those prices down.

Beyond that, we also offer a comprehensive solution called Optum Rx Weight Engage for our clients. Part of this is utilization management, where we ensure that the medication is given to those who meet a drug’s clinical criteria and is getting to those who need it the most. In addition, we offer a behavior change program for patients and this helps support them on their medication journey.

We're proud to offer many different options that clients can choose from including one that is provider guided and one that is member driven.

GLP-1s are an area where we remain restless. We understand how big of a challenge this is for our clients and members. There’s a tremendous amount of energy focused on this inside Optum Rx and you will see us bring forth new solutions in 2025 that help address this need.

Scott: Mike you are out in the market, every day. Outside of the GLP-1s, what other key market dynamics and client challenges are you seeing?

Mike: I talk to consultants on a daily basis and right after GLP-1s, we’ll talk about the impact of biosimilars entering the market. Pharmacy benefit sponsors need help navigating high wholesale acquisition cost (WAC) products, low WAC products, the impact to rebates and the impact to net cost.

Another area where they need help is with cell and gene therapies. These are critical medications and incredible advancements in medicine, but a single gene therapy can cost over $3,000,000 for a one-time treatment. So, plan sponsors need our help to limit their financial risk while maintaining critical access. And it’s not just gene therapies, there are now approximately 160 medications that cost over $250,000 a year.

One more thing we talk about quite regularly is the regulatory environment. There are multiple pieces of legislation, both newly signed and emerging, that impact the industry in big ways. Some of these include steerage limitations and rules about home delivery versus retail as well as pricing pass-through regulations that limit plan sponsor choice.

All of these can increase costs for plan sponsors. There are also changes to Medicare Part D from the Inflation Reduction Act (IRA) including a mandate to offer the option to pay out-of-pocket costs in monthly payments instead of all at once.

Scott: Sid, what about from your perspective?

Sid: We're certainly watching the orphan drug and gene therapy pipeline and finding ways to provide clients protection against volatility. As Mike noted, our Gene Therapy Risk Protection provides coverage for these multimillion-dollar therapies for a small per member per month fee. We're also exploring innovative financial models and value-based arrangements where plan sponsors would pay for gene therapy over time.

More broadly, specialty medications continue to pose challenges. Our portfolio of specialty medication management solutions enable clients to forecast trends, ensure best site of care, and provide ongoing review to ensure the spend is appropriate. We tie all of these elements together to work cohesively in our unique Optum® Specialty Fusion™ offering.

This solution integrates management of medical and pharmacy benefits to determine optimal coverage, simplifying care for patients with complex conditions and lowering the cost of expensive specialty drugs. Also, our specialty pharmacy runs Savings IQ which automatically matches eligible patients with saving opportunities and has saved over $2.5 billion dollars in 2024. So, our approach to managing specialty medications is quite comprehensive.

And finally, Mike mentioned the prescription payment plans under the IRA. The Medicare Prescription Payment Plan is a great example of where we spotted a market need early and crafted an innovative product. We are proud to be the only major PBM with an end-to-end solution for health plans so that they can remain compliant with this mandate and offer their members the benefit of spreading out their out-of-pocket costs. This drives affordability and adherence, things that we’re very passionate about here at Optum Rx.

Scott: Most of what you have pointed out so far is really from the perspective of a plan sponsor. Can you talk a little bit about some of the biggest challenges facing consumers?

Mike: Yeah, the top of the list of concerns for consumers is cost and that is closely followed by cost again. One in four Americans struggle to afford their medications. One in five adults actually skipped their medication as prescribed, versus one in 10 in other developed countries.

And if cost and cost weren't the only two issues that members had to face, they're bombarded with advertising every time they turn on the TV. There’s a miracle medication that's going to cure their ailment or make them feel better. And while many of those medications are very good, members don't have all the information they need about what's the right drug for them at the right time.

Sid: So first and foremost, we negotiate with pharma and pharmacies to lower the cost of prescription drugs. We also offer a suite of programs that are both provider and consumer-facing to help drive savings. Earlier, Mike mentioned PreCheck MyScript and the transparency benefits of giving prescribers real-time drug cost information. It also unlocks cost savings for the member who can save an average of $119 per prescription when switching to the lower-cost alternative drugs suggested to the prescriber by PCMS.

Another big step in member affordability is the Optum Rx Critical Drug Affordability program. It offers low or $0.00 cost-sharing on more than 170 essential medications. As a result of this program,98% of all Optum Rx consumers have access to insulin for $35 or less per month.

And finally, I'll mention Optum Home Delivery, where 51% of the prescriptions had a $0.00 copay last year. We're looking to continue to innovate in these areas, enhancing current solutions and of course, developing new ones.

Scott: Sid, can you give us a sense of innovation as a discipline? How does Optum Rx think about future innovation and making it a sustainable process?

Sid: It's very tempting to get attracted to the latest shiny object. Instead, we take a very disciplined and methodical approach to innovation that is focused on outcomes for our members and our clients. Today we have 30 to 40 products at various stages of development. Now, not all of these will come to market, but we have a healthy pipeline that addresses the varied needs that our constituents have. So, I would characterize our focus in five key areas.

• First, is around improving consumer affordability and experience.
• Second is around controlling specialty costs.
• Third is around transforming the pharmacy benefit — the core of what we do on a daily basis.
• Fourth is innovations that go beyond pharmacy and consider the total cost of care and helping people get well.
• And fifth but not least is around advancing emerging frontiers.

These are the new, the innovative, the shiny things that we want to keep an eye on but will bring to market only once we have confidence in the value that the solution creates.

Some specific examples that you will see us come to market with here in 2025 include the expansion of GLP-1 solutions and new specialty solutions, both of which we know are top of mind for our clients. You will also see solutions in oncology, Women's Health and behavioral health, to name a few. So, it's a very exciting time here at Optum Rx!

Scott: Mike, any thoughts about emerging solutions and what might be around the corner in the not-so-distant future?

Mike: Well, first, I want to say it's a pleasure to work with Sid and his team and be able to roll all these solutions out to the marketplace that are so beneficial for our clients and their members. A couple that comes to mind right now.

From a member and provider experience perspective, we're working through and have launched low-touch, no-touch prior authorizations. This eliminates the need for providers and their administrative staff to go through lengthy clinical questionnaires. Instead, it's automated clinical data retrieval and approval right through the EHR workflow of the provider and electronic prior authorization connectivity.

For providers, it reduces the burden by eliminating duplicative clinical documentation.

For patients, it expedites access to their medications.

For our clients, we're currently rolling out Optum Rx Benefit Central. It's a reimagined, simplified client portal experience. It's an intuitive design and self-service plan management with a new user-friendly interface. Really, at its core, we're allowing access to automated plan builds with flexible, accurate information and enhanced client reporting. Without reporting, our clients are flying blind. This gives them dynamic real-time data and actionable insights when they need it without having to rely on contacting their account teams.

This is just one of the many examples we talked about today of innovating to provide transparent access to information for all stakeholders when they need it and how they need it.