Pharmacy spotlight: Cost control and simplicity through integration

In a rapidly changing industry with rising costs and chronic conditions, it’s more important than ever for employers to find solutions to manage their medical and pharmacy spend while supporting their employee population. These challenges include:

  • About 25% of Americans have 2 or more chronic conditions.1 One in 3 adults could have diabetes by 2050.2 And 1 in 5 adults will develop heart failure.3
  • About 20% of Americans are taking 3 or more medications.4
  • New specialty medications offer potential for patients living with serious, complex conditions, but are extremely expensive, accounting for 2% of all prescriptions written and 50% of total drug spend.5

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 $16-$25 per member per month,up to a 11%-15% reduction in ER visits7 and inpatient admits costs, and an 11%-18% increase in medication adherence for top chronic conditions.8

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 from $16-$25 per member per month.

“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. “Our comprehensive approach addresses medical and pharmacy coverage with programs that wrap around the member. We also have the experience working across teams and resources to implement the overall management of these programs.” 

Integration in action

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

Specialty medications are only used by 1%–2% of the population,9 but the treatments are extremely costly. When about 45% 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 they need for improved health. This can include educating members about their treatment, notifying doctors when a prescription is abandoned at the pharmacy, sending proactive refill reminders and alerting prescribers to potential drug safety issues. 

For example, Marla,* who is undergoing cancer treatment, represents countless people being treated for comorbid conditions. She needs oral medication and infusion therapy to treat her cancer and gets help for depression. Her care has included:

  • Identifying the best medication regimen specifically for her -- the coordinated care team can verify the physician has used genetic testing to determine which therapy will work best for her cancer.
  • Maria’s physician is provided oncology treatment options based on national guidelines to help identify the most appropriate cancer treatment as well as options to select a UnitedHealthcare designated oncology pathway for her particular type of cancer.
  • A streamlined authorization process for her cancer therapy based on her specific treatment plan. Her oncologist has full line of sight to coordinated and timely medication approval.
  • Determining she could be treated from the convenience and comfort of home, helping to reduce employee and employer costs. Based on an innovative program in development, Maria could receive Herceptin at home. The pilot shows an estimated savings of $4,000 per infusion.11 On average, when site of care is optimized through home infusion, employers save 30%–50%.12
  • Additionally, by partnering with Maria’s provider, it may be appropriate to switch to Kanjinti, a preferred lower-cost biosimilar option for Herceptin with no evidence of clinical differences. This kind of biosimilar management strategy can help employers achieve additional savings of about 35%–40%.13

“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.”

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.

For example, Roctavian is expected to be the first FDA-approved gene therapy for hemophilia A at the end of summer 2020. Potential management strategies and the estimated number of members for potential treatment has been determined by UnitedHealthcare ahead of approval. The management strategy accounts for the full picture of spend across both the pharmacy and medical benefits since treatment options for many top categories of drugs fall under both.

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.14

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. Integrated pharmacy and medical benefits work together to enable full coordination for each employee.

“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.”



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.

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.


  1. Centers for Disease Control and Prevention. Multiple Chronic Conditions. August 2018.
  2. American Diabetes Association. Fast Facts: Data and Statistics about Diabetes. Revised December 2015.
  3. American Heart Association. Understand Your Risk for Heart Failure. May 2017.
  4. Multiple Chronic Conditions in the United States, RAND Corporation, 2017.
  5. IQVIA Institute Report, March 2018.
  6. The average per member per month medical cost savings is $11–$16. Actual guaranteed savings will vary based on benefit, program design and population size. Study based on 2017 claims data for 3.3M members measuring the medical savings impact of synchronized medical and pharmacy benefits and capabilities.
  7. Based on 2017 claims data for 3.3M members measuring the medical savings impact of synchronized medical and pharmacy benefits and capabilities.
  8. Based on 2017 claims data for 3.3M members measuring the medical savings impact of synchronized medical and pharmacy benefits and capabilities.
  9. OptumRx commercial clients, calendar year 2018 data. Note: Average ingredient cost can have wide variation based on drug mix within a specific population.
  10. Based on UnitedHealthcare fully insured data, Jan.-Sept. 2018, post-rebate, allowed amount.
  11. Site-of-care MedExpress pilot program, 2019.
  12. Legacy commercial fully insured UnitedHealthcare site-of-care shift savings, May 2018. Inflammatory Medication Site of Care is an add-on.
  13. Projected savings analysis based on 2018 UnitedHealthcare book-of-business claims data.
  14. 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.