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The business environment for PBMs is changing at a terrific pace, with mergers, acquisitions and new partnerships drastically altering the status quo. Exactly how this will play out remains to be seen. However, it seems fair to say that the expectations around how PBMs work are undergoing a fundamental change.

Three themes in particular stand out amid the change: drug pricing and transparency, out-of-pocket costs, and PBM business models. And while in one sense these concerns are very much in the moment, in reality, OptumRx has been driving toward solutions for these for some time.

Over the last several years, OptumRx has continuously launched products, tools and strategies aimed at exactly these problems – drug pricing, transparency, and transforming the PBM model. And we are by no means done. We continue to invest in and expand these initiatives.

In this article we will take a closer look at each of these themes and demonstrate how OptumRx is transforming. By linking to past articles from our Thought Leadership series, you can see for yourself how we are re-making our business in such a way, and at such a pace, that we are not just reacting to change, we are driving change; and rapidly mastering the new expectations we face.

Drug Pricing and Transparency

Making drug prices more transparent has become increasingly important. For OptumRx, transparency is about trust. We believe that trust can only come about when we provide proper clarity into our business practices and how our core pharmacy care services deliver value.

For clients, OptumRx is leading the charge in transparency and innovative supply chain strategies:

  • As costly therapies enter the marketplace, our strategy is aimed at moving past the traditional PBM business model of generating profits through rebate management and retail pharmacy spread. Instead, our new, transparent model is to achieve the lowest net cost for each drug category for our clients.
  • Also, 100% of our drug supply chain contracts include Price Protection. OptumRx has a unique approach to this commonly used contracting tool. Our cumulative price protection works to increase savings as drug prices increase – regardless of how or when those prices go up. The net effect is increased stability and predictability, while helping to limit the rise of drug prices for our clients.

Access and Affordability

While the majority of Americans spend very little for out-of-pocket costs for prescription drugs, a growing number of benefit designs now apply increased cost-sharing requirements to specialty drugs. For the very small number of patients (~1%) who require costly specialty medications, the cost burden can be higher if they are enrolled in this type of plan.

OptumRx has evolved a comprehensive set of strategies designed to maximize patient access to the medications they need:

PBM Business Models

One of the key questions moving forward is what will become of the traditional pharmacy benefit manager business model.

OptumRx chooses instead to ask a simple question: How can we drive better outcomes and care for patients vs. simply managing drug costs? The answer lies in our synchronized approach.

Synchronization means taking disparate, uncoordinated areas in health care, and making them work better together. Synchronization allows us to impact more than just pharmacy care. Now we can impact the patient’s medical care or behavioral health care by sharing information and prioritizing opportunities, which traditional PBMs do not impact.

  • OptumRx is changing the traditional PBM model with our broad and deep connections across the entire health system. This is why we refer to our approach as Pharmacy Care Services, because our efforts leverage pharmacy to address overall cost and care.
  • Clients realize significant financial advantages when they fully synchronize their medical and clinical benefits with OptumRx. Study results demonstrate reduced inpatient admissions and ER visits, as well as overall per-member per-month (PMPM) medical savings ranging from $11 - $16.
  • One of the clearest examples of this new connectivity is our coordinated approach to the national health care crisis of opioid abuse, which blends clinical, analytic and administrative services. Leveraging our broad and deep connections across the health care system, our opioid management efforts target all of the key stakeholders: prescribers, pharmacies, pharmacists and individual members.
  • OptumRx is also distinguishing itself among its peers through Optum IQ.™ OptumIQ combines curated data, leading analytics, and health care intelligence to create a comprehensive view of quality, cost and access. These insights allow us to impact cost and clinical outcomes not just at the client level, but also down to the individual person.

Optum is fundamentally changing the marketplace by infusing transparency and connections across the entire health system. We are using our deep knowledge of the entire health care system in order to deliver high-value, high-quality care that benefits clients and consumers alike.

For more information please contact:

Sylvia Fijalkowski | OptumRx
Strategic Account Executive, Labor & Trust, Client Management
P.O. Box 9472
Minneapolis, MN 55440
Phone: (612) 395-8542
Mobile: (773) 630-5575

Zachary French | OptumRx
Area Vice President, Central Region Sales Labor & Trust Market
Minneola, FL 34715
Phone: (763) 732-3953
Mobile: (630) 818-7912
Fax: (888) 868-1527