UnitedHealth’s pharmacy benefit management division Optum Rx announced Wednesday it will remove prior authorization requirements for approximately 80 medications, marking a significant shift in policy aimed at improving patient access to essential treatments.
The initiative, set to launch May 1, will specifically target reauthorizations – the process where patients must obtain renewed approval for medications they already use. The change is expected to reduce total reauthorizations by up to 25% and cut overall prior authorization requirements by 10%.
The affected medications span multiple therapeutic areas including high cholesterol management, lung disease treatments, multiple sclerosis therapies, and migraine medications. The company indicated it plans to expand this policy to additional drugs in the future.
Prior authorization has long been a contentious issue in healthcare delivery. While insurers and pharmacy benefit managers (PBMs) maintain these requirements help control unnecessary spending and ensure treatment safety, healthcare providers argue the process creates excessive administrative burden and can dangerously delay patient care. Some cases of severe health outcomes and patient deaths have been linked to prior authorization delays.
According to Optum Rx, while reauthorizations serve important purposes like monitoring drug safety and dosage appropriateness, many medications demonstrate “minimal additional value” from ongoing reauthorization requirements. The company specified that drugs selected for this program must meet specific criteria: they should pose no additional safety risks, demonstrate established long-term effectiveness, maintain consistent dosing requirements, and be prescribed to patients with confirmed chronic conditions who have considered alternative treatments.
Patrick Conway, Optum Rx’s CEO, emphasized that the policy change aims to streamline patient experiences, enhance medication access, and reduce administrative workload for healthcare providers.
This move comes amid increasing scrutiny of PBMs, particularly the “Big Three” which includes Optum Rx, CVS Caremark, and Express Scripts. These companies face mounting pressure from antitrust regulators and lawmakers over their alleged role in driving up medication costs through complex contracts and rebating practices.
The timing suggests a strategic response to this pressure, as PBMs attempt to demonstrate greater transparency and efficiency in their operations. Earlier this year, Optum Rx announced plans to phase out models allowing them to retain savings from drugmaker negotiations over the next three years. Similarly, all three major PBMs have introduced more transparent business models based on net drug costs, likely in response to growing criticism of their traditional practices.
The financial stakes are significant – Optum Rx generated $5.8 billion in profit last year, representing nearly 20% of UnitedHealth’s total operating earnings. By implementing such changes voluntarily, PBMs may hope to maintain control over their business practices rather than face more stringent external regulation.
This development follows similar moves by other major healthcare players, including Optum Rx’s sister company UnitedHealthcare and CVS-owned Aetna, who have also reduced prior authorization
requirements in recent years. However, healthcare providers continue to advocate for more comprehensive reforms, particularly regarding automated prior authorization processes which have raised concerns about algorithmic denial of coverage.
For implementation, Optum Rx confirmed that future additions to this program will follow the same clinical criteria currently being applied. The company’s spokesperson emphasized that patient safety and treatment effectiveness remain primary considerations in determining which medications qualify for authorization requirement elimination.