UnitedHealth Group’s pharmacy benefit manager Optum Rx announced Wednesday it will discontinue prior authorization requirements for approximately 80 medications, marking a significant shift in policy that aims to improve healthcare access and reduce administrative burden.
The changes, set to take effect May 1, will specifically target reauthorizations – the process of requiring renewed approvals for medications patients are already taking. The initiative 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. Optum Rx indicates it plans to expand this policy to additional drugs in the future, following specific clinical criteria.
Prior authorization has long been a contentious issue in healthcare delivery. While insurers and PBMs maintain these requirements help control unnecessary costs and ensure treatment safety, healthcare providers argue the process creates excessive paperwork and delays patient care. Some cases of severe health complications and patient deaths have been linked to prior authorization delays.
The announcement comes amid growing pressure on health insurance companies and PBMs to reform their authorization practices. Other major players, including UnitedHealthcare and Aetna, have already implemented similar policy changes in recent years.
According to Optum Rx, drugs eligible for reauthorization elimination 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, CEO of Optum Rx, emphasized that the program aims to enhance patient experience, broaden medication access, and decrease workload for healthcare providers and pharmacists.
The policy shift can also be viewed within the broader context of mounting scrutiny faced by major PBMs. As one of the “Big Three” PBMs in the United States, Optum Rx has faced criticism from antitrust regulators and lawmakers regarding drug pricing practices and market consolidation.
The company has been implementing various internal changes in response to public pressure. In January, Optum Rx announced plans to phase out models allowing retention of savings from drugmaker negotiations over the next three years. Along with competitors Express Scripts and Caremark, the company has also introduced more transparent PBM models based on net drug costs.
These changes come as PBMs face increased regulatory attention and potential reform measures from Washington, though concrete legislative action has yet to materialize despite several proposed bills and ongoing Federal Trade Commission investigations.
The financial stakes are significant – Optum Rx generated $5.8 billion in profit last year, representing nearly 20% of UnitedHealth’s total operating earnings. Industry analysts suggest these voluntary reforms by major PBMs are likely motivated by a desire to protect their profitable business models from more stringent external regulation.
The new policy will affect several prominent medications, including Amgen’s Repatha, Novartis’s Leqvio, and Pfizer’s Nurtec. Looking ahead, Optum Rx states that future drugs considered for inclusion in the program will need to meet the same clinical criteria as the initial group of medications.
This development represents a notable shift in how one of healthcare’s largest middlemen manages medication access, potentially setting precedent for further industry reforms while attempting to address long-standing criticisms of PBM practices.