Revolutionizing the Rx experience
Working together to help make the pharmacy care experience easier to navigate for providers, pharmacists and employees.
- Rising drug costs, especially when it comes to specialty drugs
- Confusion over which medications are covered and which are not
- Difficulties navigating the health system
By figuring out how to alleviate these issues in the pharmacy space, employers and employees alike can benefit from a more efficient and personalized approach to health care.
Controlling costs amid rising drug prices
There are several innovative strategies insurers are taking to help employees get the medications they need quickly and efficiently while also managing costs, such as developing digital tools that help providers and pharmacists understand which medications are covered.
“We are constantly evaluating new drugs long before they even come to market in order to understand their place in therapy, determine the coverage options and negotiate the best prices for our members.”
“For instance, we’re in the midst of developing our strategy around gene therapy drugs that target specific genetic markers and coverage for drugs that treat mental health, such as the new drug for postpartum depression that was approved by the FDA in August 2023,” Maddux adds.
In addition to cost discussions with pharmaceutical manufacturers, the same conversation is being made possible between providers and members thanks to price-comparison tools.
These tools allow providers and members to compare drug prices between multiple sources to find the lowest cost available for an equivalent drug, ensuring providers consider a patient’s coverage and cost information before writing a prescription and giving patients more say in regards to the price they have to pay when they arrive at the pharmacy. They can also provide real-time data on drug availability across manufacturers, so providers and pharmacists can ensure the medications their patients need are in stock.
- PreCheck MyScript® is a real-time benefits tool that allows providers to view a member’s cost and coverage details at the point of care for certain drugs and prescriptions, saving employers an average of $87 per script2
- Proactive Savings Alerts provide timely digital notifications with actionable directions and summaries of all savings opportunities, saving employees an average of $39 per month and employers an average of $103 per month3
Taking steps to reduce out-of-pocket costs can also be a way to help make the cost of pharmacy care less crippling for employees, especially when it comes to potentially life-saving drugs or therapies. UnitedHealthcare, for example, made 5 critical drugs available at $0 cost through its ground-breaking Vital Medication Program, which removed out-of-pocket costs altogether for insulin (for diabetes), epinephrine (for severe allergic reactions), glucagon (for hypoglycemia), naloxone (for opioid overdose) and albuterol (for asthma attacks).
Creating a simpler, more supportive pharmacy experience
Integrating medical and pharmacy care can also bring about improved health outcomes and a simpler, more connected experience for employees.4 When these benefits are integrated, it creates a more comprehensive view of an individual’s health needs, enabling health care providers to make informed decisions on treatments, as well as identify any potential drug interactions that could arise. The result?
- Improved clinical outcomes – New pharmacy claims can often indicate a change in an employee’s health status. With full visibility across pharmacy and medical, these claims can trigger referrals to other clinical care programs, which may lead to better management of chronic conditions
- Simplified member experience – When pharmacy is integrated within a health plan, employees can use one ID card and one digital access point to view their benefits
- Streamlined provider experience – For providers, this integration can help deliver a more seamless experience with less administrative burden
- Lower overall costs – Integrated benefits can provide visibility into available treatment options or alternatives and the costs associated with those treatments, which may lead to more informed decisions
A cross-benefit strategy that considers all angles can help ensure an employee is prescribed a drug or treatment that is clinically appropriate and cost-effective based on their medical needs. Let’s say a provider is faced with two treatment options: a medical shot that costs $20,000 every other month or a generic oral treatment that costs $2,000 per year. If an employee has separate medical and pharmacy benefit carriers, they may end up receiving the $20,000 shot, because their carrier and pharmacy benefit manager (PBM) don’t realize they have options under both benefits.
Other ways insurers are working to simplify the pharmacy experience include streamlining the prior authorization process — with UnitedHealthcare eliminating nearly 20% of current prior authorizations for common procedures and prescriptions — and redesigning web and mobile app experiences, allowing employees to more easily view their medications, as well as order, track and pay for them through an array of payment options such as health savings accounts (HSA) and Apple Wallet Digital Card IDs.
“Our goal is to provide a completely integrated medical and pharmacy experience. We can do that by leading with care and intersecting with coverage to help employees navigate the system.”
Leveraging specialty pharmacy care
A specialty medication may be injected, infused, taken by mouth or inhaled. It’s different from other drugs because it may:
- Need ongoing clinical oversight and extra patient education
- Have unique storage or shipping needs
- Not be available at retail pharmacies
Specialty pharmacies dispense these medications and offer many advantages including access to high-cost, high-complexity therapies and targeted financial assistance through copay card programs and other sources.
The personalized service and high-touch support that specialty pharmacies provide is particularly beneficial for people living with complex, chronic health conditions like cancer or multiple sclerosis. Patients have access to a team of specialty pharmacists, nurses and other professionals who provide expert guidance about their condition and treatment plan. This may include instructions for administering a complex therapy, management of side effects and referrals for helpful resources like nutrition counseling or mental health support. This level of care is generally not available from traditional pharmacies.
Optum Specialty Pharmacy provides clinical support and simplifies the experience, giving employees the ability to refill and track specialty drug prescriptions, pay online and get live support through 1-on-1 virtual visits, live chat, phone calls and follow-up consultations. This can take the uncertainty out of treatment and allow employees to focus on their health and quality of life.