Optum

4 keys to specialty medication management

Left arrow. Click to go back 1 four small dots in a row 2 four small dots in a row 3 four small dots in a row 4 Right arrow. Click to advance

Innovative medical management

  • MedicalRx Specialty Provider Network

    The cost of professionally administered medications varies significantly — as does the benefit used — depending on whether the site of care is hospital outpatient, the patient’s home, an infusion center or a physician’s office. The MedicalRx Specialty Provider Network helps control these cost variations across benefits by having network providers:

    • Use their class-of-trade discounts to get medications at lower cost
    • Administer medications wherever it’s clinically appropriate
    • Accept standardized, fair-market reimbursement for combined medication, materials and service claims

  • MedicalRx Rebates

    Plan sponsors can manage medical claim costs, reduce their administrative burden and minimize member disruption by capturing rebates for medications administered under the medical benefits.

  • Medical Benefit Optimization

    Certain specialty drugs cost less on the pharmacy benefit than the medical benefit. Medical Benefit Optimization blocks medical claims for specific specialty medications and works with providers to have Optum Specialty Pharmacy deliver the medication in advance of a patient’s appointment.

  • Gene Therapy Risk Protection

    Gene Therapy Risk Protection lets you provide clinically appropriate access to ultra-high-cost gene therapies while managing the financial risk they pose. Instead of paying an unexpected million-dollar gene therapy claim, you pay a manageable, predictable PMPM fee for gene therapy coverage.

  1. IQVIA Institute. The Use of Medicines in the U.S. Published May 27, 2021. Accessed Sept. 29, 2021.
  2. Optum Specialty Pharmacy. Internal analysis of split fill program. 2020.
  3. Optum. Modeling and analysis based on Optum Rx internal book of business data. 2022.
  4. 95% stat for Optum Connections video series. Optum internal data. Based on ongoing patient surveys. 2021.
  5. $133.4 million in foundation-based patient financial assistance Optum Specialty Pharmacy. Patient Assistance Active Grant Report. January 2023.
  6. 785.9 million in copay card assistance Optum. Copay card assistance totals report. January 2023.
  7. 94% improved/maintained adherence Optum. Internal analysis. April 2023.
  8. Reduce costs by $0.39–$1.26 PMPM for specialty redirection Optum internal analysis. Savings are estimates and may vary by client. 2021.
  9. Reduce costs by $7.80–$8.40 PMPM for MedicalRx Rebates Optum commercial claims data. January to June 2020.
  10. Reduce costs by up to $3.28 PMPM for Medical Benefit Optimization Optum internal analysis of 20 million lives. 2020.
  11. Reduce costs by up to $1.38 PMPM for Medical Rx Specialty Provider Network Optum internal analysis based on 18.5 million commercial lives from Jan. 1, 2019 to Sept. 3, 2020.
  12. $15 PMPM savings with specialty fusion Optum internal analysis. Actual savings potential will vary based on plan sponsors who have low to highly managed programs in place. March 2022.