UnitedHealth’s pharmacy benefit manager subsidiary Optum Rx announced Wednesday it will discontinue prior authorization requirements for approximately 80 medications, addressing a significant source of frustration for healthcare providers and patients.
The policy change, set to take effect May 1, will specifically target reauthorizations – the process of obtaining renewed approval for medications already being used by patients. The initiative is expected to reduce total reauthorizations by up to 25% and cut overall prior authorization requirements by 10%, according to the company.
The affected medications span multiple therapeutic areas including high cholesterol management, lung disease treatments, multiple sclerosis therapies, and migraine medications. Optum Rx indicated its intention to expand this policy to additional drugs in the future.
Prior authorization has long been a contentious issue in healthcare delivery. While insurers and PBMs maintain these requirements help control unnecessary healthcare spending and ensure treatment safety and efficacy, medical professionals argue the process creates excessive administrative burden and delays patient care. Some cases have resulted in severe health consequences or patient deaths due to authorization delays.
The announcement comes amid growing pressure on healthcare and pharmaceutical benefit managers to reform their authorization practices. Several major insurance providers, including
UnitedHealthcare and Aetna, have recently scaled back their prior authorization requirements.
Optum Rx specified that drugs qualifying for the program must meet specific criteria: they should pose no additional safety risks, demonstrate established long-term effectiveness, and maintain consistent dosing requirements. Additionally, patients must have a confirmed chronic condition diagnosis and have considered alternative treatment options.
The move can be viewed within the broader context of mounting scrutiny facing major PBMs. As one of the “Big Three” pharmacy benefit managers in the United States, Optum Rx has faced criticism from antitrust regulators and lawmakers regarding drug pricing practices. The industry has been challenged over lack of transparency in contracts, rebating practices, and market concentration.
Despite increasing legislative attention and an ongoing Federal Trade Commission investigation, concrete regulatory changes have yet to materialize. In response to public pressure, major PBMs have implemented various internal reforms. Earlier this year, Optum Rx announced plans to phase out models allowing retention of drugmaker negotiation savings over the next three years.
The company, which generated $5.8 billion in profit last year – approximately one-fifth of UnitedHealth’s total operating earnings – has joined competitors Express Scripts and Caremark in launching more transparent business models based on net drug costs. Industry analysts suggest these changes are likely responses to client dissatisfaction with complex business practices and attempts to preempt stricter external regulation.
The prior authorization reduction program represents another step in this direction, with Optum Rx CEO Patrick Conway stating the initiative aims to simplify patient experiences, improve medication access, and reduce administrative burden for healthcare providers and pharmacists.
While medical professionals continue advocating for more comprehensive reform, particularly regarding automated authorization processes that may lead to inappropriate denials, the industry appears to be taking incremental steps toward addressing longstanding concerns about healthcare access and administrative efficiency.
The program will affect several major pharmaceutical products, including Amgen’s Repatha, Novartis’s Leqvio, and Pfizer’s Nurtec, among others. Optum Rx has indicated that future additions to the program will be evaluated using the same clinical criteria established for the initial group of medications.