Dive Brief:
- UnitedHealth’s Optum Rx further cut the number of drugs subject to reauthorization requirements effective Tuesday in an ongoing effort to boost patients’ access to care.
- The pharmacy benefit manager removed reauthorization requirements — when medications currently used by a patient need to be reapproved by their plan — for over 60 drugs used to treat seven chronic conditions, including HIV, dry eye disease, high cholesterol and hypertension.
- The PBM has been seeking to reduce the number of drugs subject to reauthorization requirements since March, when it eliminated reauthorization approvals for approximately 80 medications.
Dive Insight:
Optum Rx’s push to reform its reauthorization policy comes amid broad scrutiny of prior authorization processes, where doctors need to get approval from insurers before they provide some services.
Patients say the insurers’ review processes can cause severe care delays, while providers argue hefty prior authorization requirements increase their paperwork burden and burnout. Some experts worry that these challenges may get even worse as payers increasingly automate prior authorization, allowing them to rapidly review and, potentially deny, claims en masse.
Optum Rx’s effort to reduce reauthorizations for some drugs comes as insurers and PBMs are implementing changes to make their prior authorization processes more transparent.
For example, last month almost 50 health insurers, urged by the Trump administration, pledged to reform prior authorization processes. UnitedHealthcare, Aetna, Cigna, Elevance, Humana and others said they will reduce the number of claims subject to prior authorization and better explain decisions and how to appeal denials by 2026.
In Optum Rx’s case, the PBM said it relied on recommendations from an independent body of pharmacists and physicians to determine which medications should be exempt from reauthorization requirements. Drugs included in the program have established long-term effectiveness and constant dose requirements, a spokesperson for Optum Rx said in March.
The PBM said the goal is to reduce barriers to care management.
“Chronic conditions affect about 60% of Americans and are the leading cause of death in the United States,” said Sumit Dutta, chief medical officer at Optum Rx, in a statement. “Eliminating reauthorization requirements for established and effective treatments underscores our commitment to make these needed drugs more accessible, which also supports better health outcomes.”
The company has also promised to make other changes in the face of ire directed at the PBM industry.
For example, earlier this year Optum Rx promised to end models that allow it to retain savings from negotiations with drugmakers over the next three years.
Meanwhile, other large PBMs, Cigna-owned Express Scripts and CVS-owned Caremark, have launched their own “transparent” PBM models, promising to reduce prices for consumers.
