In a significant move to streamline healthcare access, UnitedHealth’s pharmacy benefit manager Optum Rx announced Wednesday it will remove prior authorization requirements for approximately 80 medications, addressing mounting criticism of healthcare intermediaries.
The initiative, set to launch May 1, will specifically target reauthorizations – the process of requiring renewed approvals for medications patients are already using. This change is expected to reduce total reauthorizations by up to 25% and cut overall prior authorizations by 10%, according to the company.
The affected medications span several therapeutic areas, including treatments for high cholesterol, lung conditions, multiple sclerosis, and migraines. Optum Rx indicated its intention to expand this policy to additional medications 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, healthcare providers 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 increasing pressure on health plans to reform their authorization practices. Several major insurers, including UnitedHealthcare and Aetna, have already implemented similar changes in recent years. However, medical professionals continue to advocate for more comprehensive reforms, particularly regarding automated authorization processes that may lead to inappropriate denials.
Optum Rx explained that while reauthorizations serve important purposes in some cases – such as monitoring drug safety, dosage appropriateness, and patient testing needs – many medications don’t require this ongoing oversight. The company’s CEO, Patrick Conway, emphasized that eliminating these requirements aims to improve patient experience, enhance medication access, and reduce workload for healthcare providers.
To qualify for authorization requirement removal, medications must meet specific criteria: they should pose no additional safety risks, demonstrate established long-term effectiveness, maintain consistent dosing requirements, and be prescribed for patients with confirmed chronic conditions who have considered alternative treatments.
The policy change also appears strategically timed, as Optum Rx and other major PBMs face intensifying scrutiny from antitrust regulators and lawmakers over their alleged role in driving up medication costs. Critics point to complex contracts, rebating practices, and market consolidation as key issues requiring federal intervention.
Despite growing momentum in Congress and ongoing Federal Trade Commission investigations, concrete regulatory changes have yet to materialize. In response, major PBMs have initiated various internal reforms to demonstrate transparency and effectiveness. Optum Rx, which generated $5.8 billion in profit last year – approximately one-fifth of UnitedHealth’s operating earnings – announced in January it would phase out models allowing retention of drugmaker negotiation savings over three years.
Similarly, Optum Rx and its competitors Express Scripts and Caremark have launched transparent PBM models based on net drug costs. Industry analysts suggest these changes likely respond to client frustration over complex business practices and aim to mitigate political and regulatory pressure.
The selection of drugs affected by this policy includes prominent medications such as Amgen’s Repatha, Novartis’s Leqvio, and Pfizer’s Nurtec, among others. Moving forward, Optum Rx will continue evaluating additional medications for inclusion in the program using the same clinical criteria established for the initial group of drugs.