Controlling costs through medical and pharmacy integration

In a rapidly changing industry with rising costs and chronic conditions, about 90% of employers say high drug prices threaten affordable employee benefits.1 It’s more important than ever for employers to find solutions to manage their medical and pharmacy spend while supporting their employee population. Challenges employers and employees face include:

  • 28% of Americans have 3 or more conditions, and this will increase 168% in 10 years2  One in 3 adults could have diabetes by 2050.3  And 1 in 5 adults will develop heart failure.4
  • About 20% of Americans are taking 3 or more medications.5
  • The 1--2% of employees who have conditions requiring specialty medications drove 59% of total drug spend across both medical and pharmacy benefits.6

UnitedHealthcare research shows that combining pharmacy benefits with medical plans is central to improving outcomes and containing costs. Integrated pharmacy solutions can realize incremental medical savings from up to $28 per member per month,7  up to an 11%--15% reduction in ER visits8 and inpatient admits costs, and up to 18% increase in medication adherence for top chronic conditions.9

“If employers can’t see the complete picture, they may have a blind spot that they don’t know about in their employee population,” says Susan Maddux, UnitedHealthcare Chief Pharmacy Officer. “We have the expertise working across teams and resources to implement the overall management of these programs focusing on right drug, right cost while creating the right experience.” 

Integrated health benefits in action

Integration happens across a combination of UnitedHealthcare medical benefits, OptumRx pharmacy care services, comprehensive clinical management programs and UnitedHealthcare health advocacy model.

When about 44% of specialty medications on average fall under the medical benefit and 55% fall under the pharmacy benefit,10  an integrated approach to managing specialty conditions makes it easier for employers to manage the costs and care teams to support employees from a 360-degree perspective.

Member support teams — health advocates, physicians, nurses and pharmacists — leverage the same integrated data systems and holistic view to provide members with the clinical assistance and guidance to help ensure the right strategy at every step. This can include educating members about their treatment, notifying doctors when a prescription is abandoned at the pharmacy, sending proactive refill reminders, connecting members with behavioral health services and alerting prescribers to potential drug safety issues. 

For example, Maria,* who has recently been diagnosed with cancer, begins her treatment path with:

The right drug

Her oncologist uses the cancer guidance program to identify a proven, cost-effective treatment regimen and receives real-time cross-benefit prior authorization approval based on clinical evidence.

The right cost

Proactive pipeline and Preferred Drug List management enables Maria to switch to a lower-cost and equally effective biosimilar drug.

The right setting

Through site of care redirection, Maria can receive Immune Globulin (IG) treatment to prevent an infection via infusion therapy in the comfort of her home. The site of care program has shifted 40-63% of treatment out of higher cost facilities.11 There is a $29,100 savings opportunity per patient per year with IG.12

The right support

Maria’s IG treatments will be provided by the same home infusion nurse. She also has 24/7 access to clinical experts via phone support and virtual visits.

“Our integrated model has been in place for more than a decade, including our data engine that analyzes vast amounts of pharmacy and medical data points and information, to find opportunities and potential issues for our members that can be addressed in an organized way by our organization,” says Paul Kiser, Senior Vice President of Client Relationships for OptumRx Commercial Markets. “We are executing on this model today and have the experience that allows us to continuously build and enhance our capabilities .”

3 Key Takeaways

  1. Medical and pharmacy integration happens across a combination of UnitedHealthcare medical benefits, OptumRx pharmacy care services and comprehensive clinical management programs. 
  2. Member support teams — health advocates, physicians, nurses and pharmacists — leverage the same integrated data systems to provide members with the clinical assistance and guidance they need for improved health.
  3. Integrated pharmacy solutions can realize incremental medical savings of up to $28 per member per month.

In addition, UnitedHealthcare monitors the pipeline of drugs seeking approval from the Food and Drug Administration to help ensure strategies benefit employers and employees in the long term.

"We start reviewing the pipeline in the pre-approval phase. When we understand what the likelihood of approval is and what would be the implications if a drug does get approved, we can start developing criteria and other strategies well in advance of when the product hits the market," Maddux says.

Building a personalized experience for employees

For employees like Maria, she’ll be able to find all of her information in one place. “There is one place to make a call for pharmacy or medical questions, and for digital tools like our app or website. When you simplify things for employees, it can lead to more engagement,” Kiser says. Employers with integrated benefits with UnitedHealthcare have 21% higher clinical engagement compared to those without integration.13

When she calls UnitedHealthcare, advocates can handle medical and pharmacy questions. They have a series of triggers to talk about with the member such as missing a medication refill. The advocate can then find out the reason to help resolve the issue.

With solutions that place employees at the center of care, they’ll experience support whether it’s a live video medication consult for a new specialty medication or finding the most affordable medications for treating a chronic condition to improve adherence. 

“Our synchronized teams, including 85,000 clinical professionals, work as one to help get employees personalized health and savings opportunities at the right time,” Maddux says. “Providers get timely information to guide health and cost decisions. The power of integrating pharmacy and medical can make a big difference in employees’ health outcomes and employers’ total cost of care.”

*Maria is not a real patient. Her story reflects the experience of multiple patients.

Managing chronic conditions through medical and specialty benefits integration

Connecting vision, dental, financial protection and medical benefits may help employers potentially lower their costs with targeted interventions, helping improve the health and experience of their employees and their families.

Integrating medical and behavioral benefits for whole-person health

By connecting these benefits, UnitedHealthcare proactively identifies members who may have untreated mental health issues and works to engage them in evidence-based care programs and treatment services.

Explore strategies for your clients

Uncover more ways to help clients save.

Discover plans, strategies and products that can improve engagement.

Find ways clients and their employees can simplify the experience, make healthier choices and lower costs.


  1. National Alliance of Healthcare Purchaser Coalitions 2020
  2. Centers for Disease Control and Prevention. Multiple Chronic Conditions. August 2018.
  3. American Diabetes Association. Fast Facts: Data and Statistics about Diabetes. Revised December 2015.
  4. American Heart Association. Understand Your Risk for Heart Failure. May 2017.
  5. Multiple Chronic Conditions in the United States, RAND Corporation, 2017.
  6. UnitedHealthcare Commercial Fully Insured data, 2020.
  7. Internal study based on 2020 analysis of 91-100 UHC national account clients data. This is not a guarantee. Actual guaranteed savings will vary based on benefit, program design and population size. 
  8. Based on 2017 claims data for 3.3M members measuring the medical savings impact of synchronized medical and pharmacy benefits and capabilities.
  9. Ibid.
  10. Based on UnitedHealthcare Commercial Fully Insured data FY 2020, post-rebate, allowed amount. Based on UnitedHealthcare fully insured data, Jan.-Sept. 2018, post-rebate, allowed amount.
  11. UnitedHealthcare Commercial Fully Insured data Oct. 2020
  12. Ibid. 
  13. Analyzed 2018 data comparing group of clients on Advocate4Me Elite package to clients not on the package. Costs were normalized for risk, age/gender, geography and other plan design factors that can impact costs. The cost comparison was validated across UnitedHealthcare’s different service locations where this cohort comparison could be analyzed with sufficient sample sizes. This is an example of potential savings — savings are not guaranteed.