Optum

4 keys to specialty medication management

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Proven pharmacy management

  • Utilization management programs

    Utilization management programs are a proactive way to manage total drug costs for plan sponsors and their members. By using strategies like step therapy and quantity limits, you can help make sure members get the most clinically appropriate, lowest-cost medication.

  • Formulary development

    Your specialty formulary should be shaped to meet the needs of the people you serve, while also managing costs. We build our formularies and utilization management programs using drug pipeline surveillance, innovative contracting, drug value, and rebate modeling.

  • Tailored networks

    Central to aligned specialty medication management is balancing cost with member access to the drugs they need to live a healthier life. Our pharmacy network options provide members convenient and affordable member access to drugs while also managing your costs.

  • Split fill

    Almost half of patients on certain oral oncology drugs discontinued their therapy within 90 days because of side effects or other challenges — an expensive loss.

    Our split fill program for oral oncology medications helps avoid early-discontinuation waste by filling half the prescription twice a month rather than a full prescription once a month. This increased frequency gives patients a chance to talk with their doctor sooner about side effects and possible adjustments.

  • Clinical management programs

    Optum Rx Specialty Standards combines three approaches to make sure an individual patient is on appropriate therapy at the lowest cost. Approaches include specialty expert reviews on highly complex medications, precision edits to optimize fills and reduce waste, and a new specialty tiering design for your formulary.

    Review My Care is an analytics-and-experts solution that brings members and prescribers opportunities to change treatment in ways that help improve both member outcomes and specialty trend management. Examples include optimizing package size, reducing oversupply caused by early refills, and ensuring clinical appropriateness when more than one drug is prescribed.

  • Copay Card Solutions

    Optum Copay Card Solutions help you reduce your share of medication costs while allowing members to use manufacturer copay cards to reduce their out-of-pocket costs. Solutions include:

    This program increases a member’s cost share enough at the point of sale to capture available dollars from a copay card. Those copay card dollars are then applied to the member’s cost share, which effectively reduces your portion the medication cost without affecting the member’s out of pocket.

    Accumulator adjustment – When a member uses a copay card to help buy their medication, this program excludes the copay card dollars from the member’s accumulators — their deductible and out-of-pocket max.

  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. 92% of U.S. population lives within 5 miles of an access point UPS. UPS Makes Delivery Easier By Handling Signatures at UPS Access Point Location Deliveries. 2020.
  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.