What’s next for AI in pharmacy?

Scott Draeger: Santiago, in this discussion we want to dig into the use of AI and other advanced technologies in pharmacy services. Can you start by giving your sense of which technologies are making the biggest impact currently and also talk about the infrastructure necessary to deploy them?

Santiago Abraham: That's a great question, Scott. You know I would say from a technological perspective, this is a pretty critical moment as there's a lot of movement and advancement in the spaces of AI and generative AI. 

It starts with really deep partnerships with what I would call the key skilled players in this space. We have really strong partnerships with Microsoft, Open AI, Google, Amazon and others that really are the foundation for a lot of the great work that's happening here. That deep partnership and collaboration really powers the tools and the technology that we're building.  

With that, I would also say talent is super, super important to really drive that technology. So, our continued focus is on training over 10,000 AI engineers here at Optum because having that workforce that can really understand how to leverage AI and bring to scale solutions that actually solve people's problems is super important.

Then finally, I'll call out that in addition to the technology and the talent, we really have to make a commitment at the enterprise level. And UHG CEO Steve Hemsley has come out really clear on our AI positioning in healthcare. We're going to be focused on leading the way and creating a dedicated space for us to invest in scaling AI and driving this transformation forward. I’m excited about the opportunity to do that with this team.

Scott: Jen, given your role guiding Optum Rx enterprise capabilities, I'm curious about the intersection of these cutting-edge technologies and the tangible improvements our clients and members expect from us. Can you talk about how you and your team approach the use of advanced technologies?

Jen McGonigle: So, my team is responsible for all of our systems and the platforms and the processes that our PBM and the pharmacies need to function. We first ensure that we take the time to really understand what the business problem is. We're trying to solve all of the pain points in that space and the opportunities we have ahead of us. 

Our internal team members are trying to leverage technology to help simplify, streamline and automate administrative functions. It's paramount for us because we've got so many pharmacists to help them work at the top of their license.  

We also have a heavy focus on the tools that improve the member and the client experience, such as self-service abilities.  

My team also brings a deep knowledge of how our operations work. So not only are we upskilled in AI, but we know how those functions process and how the systems work so that we can help improve them. In fact, one of my team members is actually taking an AI course at MIT, so everybody's been upskilled across my team of 400.  

We work super close with Santiago's team. We also understand the broader pharmacy ecosystem and how it all works — prescribing real-time benefit checks, the rules that the claims run on. This helps us optimize our internal platforms and how we integrate with the exterior pharmacy ecosystem so that we can reduce the member abrasion points, get patients onto therapy faster, lessen the administrative burden for providers and just help everybody get to the therapy they need as fast as possible.

Scott: Jen, you mentioned the member experience. Could you highlight a few areas where they are seeing the most immediate impact from advanced technologies?

Jen: Yeah, for sure. We've got so much data at Optum Rx and AI is allowing us to use that vast amount of data to anticipate what the member needs. We can use that data to help predict why they're calling and then proactively resolve those issues and give them personalized care. 

We've got a couple of member AI solutions live in production today. One of them looks at the consumer data and predicts if the member is going to run into an issue so that we can get ahead of it and proactively resolve it before they even notice.  

Another one predicts why the member is calling our call center and it allows us to offer personalized self-service options and help them to the right advocate who can solve their problem. It also provides the advocate on the other end with the likely reasons for why they're calling so that they can enter the call “warm” with an understanding of the situation that the member is in.  

What's great is that these two solutions have helped us prevent issues, they've helped us resolve member issues faster, and then at the end of the day, we have obviated over 4 million calls this year with the help of these two solutions. 

Another one that I'm really excited about and is currently in development is our new Optum assistant for members. Our members will have access to that via the portal or the mobile app, and it's really a conversational agent that allows them to type in questions like “why did my claim reject at the pharmacy” or “what actions can I take to get my prescription?”  You know, one question might be “help me save money on our prescriptions” and our AI agent and assistant will return generic options that are on formulary or help them find pharmacies that are close to them where they can save money.  

This is really great technology and it's going to greatly simplify the healthcare experience for them. As intuitive as our portal and app are, we just can't expect members to know how to navigate to every page and menu item, so this assistant simplifies that experience and just kind of puts the power of self-service in their hands.

Scott: Santiago, how about for our clients, the plan sponsors. Where are we seeing measurable impacts for them?

Santiago: Yeah. Great question, Scott.  Let's start with continuing the thread where Jen was mentioning the member experience. That simplicity matters to our clients as well. We’re also bringing that same Optum assistant capability into Benefit Central, our one-stop shop experience for our clients. Bringing Optum assistant there will empower our clients to ask similar questions, maybe click in to understand more about utilization management and prior authorizations. Really any element that they want to understand from a benefit perspective and how we're executing.  

We’re also focusing on value with our clients. So, things like AI-powered trend management tools help them understand what's going on from a plan perspective and how they can ultimately take actions to change their trajectory. Going even further, we want to help with plan design, getting to an assistant that can aid in plan design and really empower our clients.

Scott: Jen, providers are really the third part of this equation. What benefits are they seeing as we embed advanced technologies into more of our operations?

Jen: I do think historically providers have been overlooked a little bit. We know that prior authorization is a source of frustration for providers. Recent stats state that about 95% of physicians said that PAs increased their burnout and 94% of providers report that prior authorizations can often lead to delays in treatment.  

However, we know that PAs are incredibly important for patient safety and affordability, so my team's challenge was to figure out a solution to help remove that administrative burden from the providers and expedite the prior authorization decision turnaround time so that we could get members on the therapy faster.  

About two years ago we partnered with Surescripts in this endeavor to cocreate a solution that automates the creation, submission and approvals of our PAs and it does it all within 30 seconds. PreCheck Prior Authorization is that Optum Rx solution and I can spend a few minutes and walk you through how it works. 

So just imagine that a patient is in the doctor's office, and the physician prescribes a new medication. Our real-time benefit check would see if a PA is needed, and if so, Optum Rx returns that codified question set back to the provider. Surescripts then reaches into the physicians EMR system and pulls out and attaches those discrete clinical data elements and it attaches those to the codified questions and then submits the prior authorization back to Optum Rx.  

So, at this point in the process, we've essentially created and submitted the PA without the physician lifting a finger. Optum Rx then runs our PA approval automation and if the utilization management clinical criteria is met, we approve the PA and return that approval status. Again, that entire process that I walked through is occurring in less than 30 seconds, from start to finish.

However, I do want to be clear that PreCheck Prior Authorization is not artificial intelligence. This solution uses codified criteria and business rules. It's been live over a year now. We piloted it with the Cleveland Clinic first and achieved 100% clinical accuracy over all of the automated approvals. 

Here are some proof points and some fun stats: we are automating about 65% of approvals and we are seeing a 75% reduction in appeals. This means that we're getting it right the first time and we're seeing a reduction in PA denials due to lack of information because the system is pulling all of the right discrete clinical elements and attaching them to the correct UM criteria. As a result, we're getting patients onto therapy up to four days faster, which is amazing. 

So, with this advanced technology solution, every stakeholder in the entire ecosystem wins. We are currently live with 14 health systems. By the end of the year, we'll have over 20 health systems live and we've got 50 plus in the pipeline. It's a really cool and amazing example of how Optum Rx innovates and cocreates with industry partners to solve some really big challenges in healthcare.

Scott: One concern that seems to persist around the use of AI is privacy and security. This is especially germane when dealing with healthcare data. Santiago, how do we ensure responsible and secure use of AI?

Santiago: It's an area that we're very focused on. We've put in place a responsible use framework that ultimately governs how we leverage AI. It’s an independent group review board that goes through clinical, legal and technical expertise to understand each use case to ensure the right level of privacy and security. Every single AI use case here at Optum goes through this process. It’s a very thoughtful process that makes sure that we're thinking about the right things before we deploy. So that's the central element of our governance around this. 

More generally speaking, our view is that AI supports but does not replace human decision making. We call that human-centered AI and there’s always a human in the middle to make sure that we're making the correct decisions in the interest of our members, our patients and those who we serve.  

In addition to that, I'll say that the AI models and the AI tools are following the same role-based access control methods that we apply to all data – there's no special side door for AI. It actually is following the exact same security controls that safeguard our data from a client and consumer perspective. So again, this is an area that we take super seriously because to your point this is healthcare data we're talking about.  We have to make sure that we're treating it in the right way.

Scott: Last question for the both of you. We know that this is evolving rapidly, but can you each pinpoint some upcoming developments that make you most excited? As we approach 2026 and beyond, what can clients and members look forward to? Santiago, let's start with you.

Santiago: Alright, there's a lot to pick from here, Scott, but I'm going to go with one of my favorites, which is affordability. Some of the demos we've done and some of the early use case work we're doing with member assistant are to drive improved affordability for our members and our patients, help them understand the options they have and help them navigate to the right drug at the right price.  

There's so much opportunity here with copay cards and other elements that come into play to help drive affordability. So, I’m just super excited about the work that we're doing in this space, can't wait to get it out there.

Scott: Jen, how about from your perspective? What can clients and members look forward to in 2026? 

Jen: Well, I love that Santiago took the affordability lens on that because of all the work that we've done with proactive savings alerts and Optum Savings IQ, which is saving our patients over a billion dollars every year.  Putting that in the moments that matter with those companions and assistants is going to be really critical. 

I'm going to take the accessibility scope and helping our members, our providers, our pharmacists, and our internal Optum Rx team members in those moments that matter to get members on the therapy faster. 

So, we talked earlier about the PreCheck Prior Authorization solution that gets patients onto therapy four days faster.  We also have some tools in production like our out-of-stock prediction tool that allows us to predict when a drug is going to go out of stock so that we can proactively order ahead and we've seen great results there. And then what I'm really excited about is we're currently developing lots of tools to solve those future problems, like how to predict reships and resends in our pharmacies. We know it's super disruptive when this happens, but we want to be able to take proactive steps to prevent those disruption events. 

The other thing I'm really excited about is ideating about how we can get Optum assistant in the hands of pharmacies. We've got a provider portal today that does allow for some self-service, but I love the idea of getting a conversational agent in the hands of the pharmacist. So, at those moments when a claim rejects the pharmacist can go in there and self-service and get the members onto therapy.  

I think empowering them to do things like selecting the overrides in scenarios where a client allows for an override, those are going to be great examples of how the member doesn't have to walk away from the pharmacy empty handed and come back. It’s about giving the pharmacist the information they need at that moment so the member can walk away with their drug.  

So, I’m just really excited to see where we can go, and how we can provide every member in the ecosystem with those assistants. I’m excited to innovate with Santiago and his team and see what we come up with next.

Scott: Jen and Santiago, thank you so much for joining us today. It was a very informative conversation.

Jen: This was fun. Thanks for having us.

Santiago: Thanks, Scott.

Scott: Thanks for listening to the Pharmacy Insights podcast. I'm your host, Scott Drager. Tune in again for more discussions as we examine the most important issues in pharmacy care services.