UnitedHealth Group’s pharmacy benefit management division, Optum Rx, has announced plans to discontinue prior authorization requirements for approximately 80 medications, marking a significant shift in healthcare access policies. The changes, set to take effect May 1, will specifically target reauthorizations – the process of requiring renewed approvals for medications that patients are already using.
The initiative aims to reduce reauthorizations by up to 25%, representing roughly 10% of all prior authorizations currently required. The affected medications span various therapeutic areas, including treatments for high cholesterol, lung disease, multiple sclerosis, and migraines.
Prior authorization has long been a contentious issue in healthcare delivery. While insurers and pharmacy benefit managers (PBMs) maintain these requirements help control unnecessary healthcare expenses and ensure treatment safety, healthcare providers argue the process creates excessive administrative burden and can lead to dangerous delays in patient care. Some cases have resulted in severe health complications or patient deaths due to authorization delays.
The announcement comes amid growing criticism of PBMs and increasing pressure for reform. Other major healthcare companies have recently made similar moves, including UnitedHealthcare and Aetna, reflecting an industry-wide response to concerns about access barriers.
According to Optum Rx, drugs selected for this program meet specific criteria: they must demonstrate minimal additional safety risks, have proven long-term effectiveness, and maintain consistent dosing requirements. Patients must also have an established chronic condition diagnosis and have considered alternative treatments to qualify for the waived authorization requirement.
Patrick Conway, Optum Rx’s CEO, emphasized that these changes are designed to enhance patient experiences, improve medication access, and reduce administrative workload for healthcare providers and pharmacists. The company has indicated plans to expand the program to additional medications in the future, applying the same clinical criteria for selection.
The timing of this policy shift coincides with increased scrutiny of major PBMs by antitrust regulators and lawmakers. As one of the “Big Three” PBMs in the United States, Optum Rx faces ongoing criticism regarding market consolidation, contract transparency, and rebating practices. The company generated $5.8 billion in profit last year, contributing nearly 20% of UnitedHealth’s total operating earnings.
This move follows other recent initiatives by Optum Rx to demonstrate greater transparency and efficiency. In January, the company announced plans to phase out models allowing retention of drugmaker negotiation savings over the next three years. Similarly, competitors Express Scripts and Caremark have launched more transparent PBM models focused on net drug costs, likely in response to mounting pressure from clients and regulators.
The Federal Trade Commission continues to investigate major PBMs, and despite numerous proposed bills in Congress, comprehensive reform legislation has yet to be enacted. Industry observers note that these voluntary changes by PBMs may represent attempts to preempt more stringent external regulations while protecting their profitable business models.
The program will impact several prominent medications, including Amgen’s Repatha, Novartis’s Leqvio, and Pfizer’s Nurtec. While the initiative represents a significant step toward reducing
administrative barriers in healthcare, medical professionals continue to advocate for broader reforms in prior authorization processes, particularly regarding the increasing use of automated systems that may lead to inappropriate denials of care.