The innovation blueprint

Innovation is inherently a balancing act. You must solve for the problems of today while keeping an eye fixed on the horizon and planning for the challenges tomorrow.1 That’s why when it comes to creating offerings for pharmacy care services, Optum Rx has developed a measured, systemic approach to innovation. While the need for innovative solutions has never been greater, so too is the array of tools that innovators have to work with. Yet, simply bolting on the latest technological trend to an existing product isn’t sufficient. Getting past the “shiny stuff” is essential before beginning the exacting work of creating high-quality solutions that make a difference not just for Optum Rx members and clients but the industry as a whole.

The framework?

Part of our disciplined approach to innovation entails making hard choices about which projects will take priority when it comes to timing and investment. We’ve identified five key areas where there is the greatest opportunity to meet the immediate needs of clients and consumers through high-quality, differentiated product and services offerings.?

• Improving consumer affordability and experience??

Creating a modern and seamless ecosystem for consumers and providers that reduces friction and simplifies engagement while also increasing awareness of lower cost options.?

• Controlling specialty drug costs??

Providing appropriate access to therapies and enabling patients to benefit from these advancements while managing their costs – whether the drug is covered on the pharmacy or medical benefit.?

• Transforming pharmacy benefit management??

Advancing the PBM industry by pursuing new ways of driving to lowest net drug cost and price transparency, including novel formulary designs, pricing models and contract innovations.?

• Managing total cost of care and helping people get well??

Assisting members in improving their health through programs focused on medication adherence, safety, and condition-specific support in areas like oncology and behavioral health.?

• Advancing emerging frontiers?

Leveraging advances in all areas of emerging science, such as artificial intelligence and machine learning (AI/ ML) and digital therapeutics.?

The challenge: Enable a universal view of drug prices and provide the lowest price for members on or off-benefit.

The innovation: Optum Rx Price Edge??

This free-to-use tool scans benefit member cost share and off-benefit pricing, then incorporates the lower price for the member while retaining claim history to monitor drug utilization. This price transparency allows members to compare on and off-benefit prices and gives plan sponsors a consolidated view of pharmacy data.

The challenge: Ultra-expensive drugs are becoming increasingly common??

The innovation: Specialty and gene therapy risk protection models??

Specialty drugs now cost many times more than non-specialty drugs, so a small population of member users adds up – especially with treatments like gene therapies that can cost up to $4 million per dose. Our risk protection models replace the costs associated with a one-time catastrophic claim with a manageable, predictable per member per month (PMPM) fee for plan sponsors.??

The challenge: Add rigor to the use of Specialty drugs to reduce costs??

The innovation: Optum Rx Specialty Standards??

This program leverages the expertise of Specialty Ambassadors within Optum. Ambassadors are integrated into the member experience by reaching out to those impacted by high out of pocket events, being available for members with questions regarding their specialty benefits, and alerting them to preferred lower-cost products.?

The challenge: Historic reimbursement models meet an evolving industry??

The innovation: Optum Rx Cost Made ClearTM??

In traditional PBM pricing, the price a retail pharmacy pays can differ from the price billed to a client. Optum Rx Cost Made Clear gives plan sponsors more choices with transparent pricing models that expand payment options beyond the traditional payment solution. These new models use a simple admin fee for member care and support, benefit setup and administration, client consultation, formulary design, clinical expertise, and safe and affordable medication access. Thus, they offer increased transparency, simply the pharmacy benefit, and better align incentives across the supply chain.??

The challenge: Covering expensive weight loss medications??

The innovation: Optum Rx Weight Engage??

GLP-1 agonists are exhibiting double-digit weight loss in many patients, but cost more than $1,000 per month. Optum Rx Weight Engage integrates medical necessity standards to control utilization and member support groups, helping members to lose weight and keep it off.?

The challenge: Help members taking multiple medications??

The innovation: Optum Rx Polypharmacy Value Management??

Polypharmacy means that one person is taking multiple medications at the same time and in many cases, there’s sound clinical reasons for taking each of those medications. The Optum Rx Polypharmacy Value Management program identifies members taking five or more chronic medications and engages with them and their physicians and our pharmacists. When appropriate, adjusting medication regiments helps reduce the cost of unnecessary prescriptions and lowers the potential health risk of adverse medical events.?

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The challenge: Give everyone a fair opportunity to be healthy??

The innovation: Optum Rx health equity initiatives??

Health equity is an ongoing challenge in getting patients the care and prescriptions they need. Optum Rx tackles this issue with dedicated analytics, engagement and activation methodologies to identify potential health inequities for members who have certain health conditions, and patient-specific financial assistance for those struggling to afford certain expensive medications. We’ve developed an array of innovations aimed at mitigating health disparities.?

The challenge: Give plan sponsors and members new options for expensive biologic drugs??

The innovation: Optum Rx biosimilar strategies??

To help spur adoption of biosimilar drugs, an inexpensive alternative to branded biologic drugs, we will continue to evaluate new entrants as they come to market. Our priority is to maintain clinical quality of care, flexibility and choice and to ensure stability of supply from the biosimilar manufacturers we evaluate.?

Optum Rx pharmacists are ready to support patients with questions about treatment options.?

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Making the blueprint work for you?

This approach to innovation isn’t about designing one new app to fix health care. It’s about employing a systemic approach to offer the most innovative pharmacy benefit solutions and ultimately better connect a disconnected health system so that it works better for the people it was created to serve.??

If you want to dig a little deeper about how we’re innovating to meet pharmacy’s challenges — today and tomorrow — check out this on-demand webinar featuring Sid Sahni or connect with an Optum Rx representative, today.?

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References??

1. Optum Rx internal analysis using 2023 metrics | 2. Deehan M. Seaport pharma firm launches world’s most expensive medicine. Axios. Mar. 2024 | 3. Optum Rx 2023 internal analysis | 4. Eli Lilly. How much should I expect to pay for Mounjaro?? | 5. Optum Rx internal analysis of 2022-2023 program results

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