Transform your pharmacy benefits with end-to-end transparency

Just because a drug is newly approved doesn’t mean it’s necessarily the best option. As a clinical first PBM, our independent Pharmacy and Therapeutics Committee (P&T) is comprised of:

• Physicians
• Pharmacists
• Clinicians 

As new medicines arrive, the P&T Committee considers the relevant data and scientific literature and whether the drug meets clinical criteria. This autonomy ensures clinical outcomes are taken into account before drug cost considerations. 

This unbiased analysis is especially essential in areas such as biosimilars where a single biologic drug will have multiple biosimilar options or with the rapidly growing GLP-1 drug class, where a single drug can be approved for multiple indications. 

Understanding formulary economics is essential to selecting the best formulary option for your plan. Using our independent P&T recommendations, our Industry Relations team solicits competitive bids from and negotiates with drug makers. 

A separate Formulary Committee then reviews those bids as well as P&T guidance to help make selections for Optum Rx formularies. Our clinical consultants and formulary strategy advisors review formulary recommendations, logic and modeling. 

Armed with this essential drug cost information and drug class designations, plan sponsors can make informed decisions that best align with the unique needs of their members.

Optum Cost Made Clear payment solutions give plan sponsors the ability to choose and configure a pricing model aligned with their principles. 

These models were designed with transparency in mind and choices include: 

• Pass-through models: Use average ingredient costs, reflect real-time price improvements and pass through 100% of rebates. 
• Cost plus/acquisition cost models: Price according to the cost of medications plus an administrative fee. 
• Reference-based models: Rely on national index cost baselines to determine drug pricing. 
• PMPM trend guarantee: Leverage rebates to lower costs and charge a per member per month fee.

Private-label medications are made by a third-party manufacturer for Optum Rx and act as a clinically equivalent but cheaper alternative to brand name drugs on formularies. 

Private-label drugs provide new levels of visibility into drug cost economics and also afford plan sponsors new options when configuring your formulary choices. 

For example, a plan sponsor could position a low WAC (Wholesale Acquisition Cost) biosimilar option favorably on their formulary as an alternative to an expensive biologic drug.

A big part of transparency is validating that the plan is performing as contracted and offering drugs on formulary at net cost parity or below while also providing the full economic benefit of rebates and discounts. 

We offer clients transparent access to multiple types of data for auditing purposes. 

• Manufacturer contract audits: View manufacturer billed rebates, reject management, collection, disbursement and reconciliation. 
• Network contract audits: View retail network contracts and claim submissions and ensure appropriate fraud, waste and abuse measures. 
• Acquisition cost audits: View drug-level acquisition cost documentation and matching to rates billed to plan. 
• Administrative audits: View prior authorization and appeal processes as well as other utilization management criteria.

Since drug prices are subject to change, managing volatility contractually is key. For generic pricing, which can swing significantly at the wholesale level as the supply of a given drug available from manufacturers changes, this is especially true. 

We have transparent and clearly established pricing guardrails that consider Maximum Allowable Cost (MAC) pricing and how often and how much prices are adjusted. Instituting these guardrails helps control costs and ensures that members do not see material month-over-month or refill-over-refill volatility when acquiring their prescriptions.

Empowering physicians and pharmacists is another way to control prescription drug spending while ensuring the patient is able to access the right therapy at the right time.

Since a physician cannot prescribe a lower cost medication without visibility into drug costs at the patient’s plan level, we have developed an industry-first innovation to provide this information to them in real time. Integrating seamlessly into a prescriber’s existing electronic workflow, PreCheck® MyScript (PCMS) enables providers to see formulary information during prescribing to better understand costs and account for utilization management requirements for a given drug.

Our latest innovation, PreCheck Prior Authorization (PCPA), also leverages a physician’s electronic records. To help expedite the prior authorization process, PCPA automatically extracts the relevant data about a patient for the prescriber, eliminating the need to manually input supporting clinical information. When used, PCPA decreases the median turnaround times for prior authorizations from hours to seconds, accelerating a patient’s path to therapy.

Total transparency requires giving members new levels of visibility into their pharmacy benefit. Our app and portal lets members know which drugs are preferred on their plan’s formulary as well as alerting them to potentially cost-saving alternatives. 

Our innovative price comparison tool Price Edge provides members with seamless, real-time visibility into lower costs for their prescription. When at a retail pharmacy, Price Edge compares available direct-to-consumer prices with insurance pricing, automatically ensuring they get the most competitive price. 

In addition, our copay card and payment assistance programs (Optum Savings IQ) increase transparency by proactively guiding members to available copay card offerings and/or payment assistance programs. 

As we’ve seen, end-to-end transparency in the pharmacy benefit requires much more than just transparent pricing. Delivering clear and verifiable information is a core value of our company. That’s why as the first comprehensive, transparent PBM, Optum Rx is committed to providing end-to-end, verifiable information that clients, members and providers need to make important cost and care decisions.