OptumRx Prior Authorization Changes: What Does It Actually Mean For Patients, Providers, and Payers

Understand Considerations for OptumRx’s PA Announcement

OptumRx (Optum) recently announced significant changes to its prior authorization program, eliminating the reauthorization process for 80 drugs in categories such as migraines, multiple sclerosis, and high cholesterol. Is this a change that is positive for the healthcare ecosystem? Just like the social media status of your friend from high school, it’s complicated. Removing or lessening the use of PAs in some circumstances can be a positive, but it may be only one piece to this puzzle that may not represent a total solution. There is the potential for poorer treatment outcomes, inappropriate use, or wasted healthcare dollars. Keep reading for a summary of the most important aspects for healthcare payers.

Overview of Optum’s Program Change

Key Highlights:

• Optum is eliminating reauthorizations for 80 drugs across 6 therapeutic categories
• Changes affect approximately 7% of overall pharmacy drug spend, according to PSG book of business analysis
• Initial prior authorization will still be required

The change by Optum is relatively simple – for 80 drugs across 6 categories, prior authorization will be required on the first fill, but reauthorization will not be required or will only be required every 2 years in the case of CGRPs for migraines. Optum cited a goal with this program change to  “simplify patient experiences and increase access to critical medications.” Additionally, the organization cited that the change would mean “less work for pharmacists and physicians, and a simplified system focused on clinical quality.”

Also, per Optum, these changes apply to members with “chronic conditions” and will include drugs within 6 therapeutic categories, including cholesterol-lowering PCSK9 inhibitors, idiopathic pulmonary fibrosis (IPF), pulmonary arterial hypertension (PAH), cystic fibrosis (CF), multiple sclerosis (MS), and CGRP migraine drugs. Optum is including drugs intended to be taken lifelong, so reauthorization would have minimal additional value for otherwise clinically-effective treatments. Additionally, Optum notes there are drugs that will not be considered for inclusion in the program as they see “reauthorizations necessary” when ongoing monitoring is required for safety concerns, dose adjustments, additional testing, or when alternative therapies could be considered.

While these changes are intended to improve the member experience and may certainly have some positive impacts, it’s worth exploring whether there might be negative impacts for patients or payers as well. We’ve identified a few areas worthy of further review by healthcare payers:

• Mavenclad is an oral MS disease-modifying therapy taken for 4 -5 days each of two consecutive months for two consecutive years.  Despite its high cost and limited two-year dosing protocol with potential malignancy risks beyond this period, it would no longer require reauthorization under the proposed changes.  With the limited treatment course, Mavenclad does not meet the description of a lifelong drug, and the indefinite approval could lead to inappropriate or unsafe use and wasted dollars.    
• PAH is a rare progressive disorder that requires changing treatment regimens as the disease advances. Eliminating reauthorization requirements may result in patients continuing unnecessary medications, causing confusion and excessive spending.
• CGRP migraine medications used for acute treatment rather than prevention don’t meet the “chronic use” definition, and removing reauthorization requirements could lead to medication overuse headaches, stockpiling, duplicate therapies, and an inability to assess treatment effectiveness.

The Role of Prior Authorization in Healthcare

Prior authorization is a common utilization management tool that can sometimes be controversial. Physicians complain that PAs add an excessive administrative burden and delays to patient care. However, healthcare payers commonly observe meaningful examples of fraud, waste, and even abuse related to medications being inappropriately prescribed. There are over 23,000 prescription medications approved by the FDA for marketing, and it is nearly impossible for physicians to understand every drug and, even more so, how much that medication costs for the plan and the member.

As more high-cost specialty drugs are available in the market, PAs can be a meaningful tool to confirm that the medication is providing the intended health outcomes and appropriate for continued use by the patient. This isn’t just about costs – patient safety is a critical consideration. Appropriate use is achieved when the right patient gets the right drug for the right diagnosis at the right dose, frequency, and duration. PAs are often required for higher-cost drugs, drugs with potential serious risks, or drugs that have clinically effective lower-cost alternatives.

Alternative first-line therapies could have positive clinical implications for some patients, as they may offer lower risks of side effects or better dosage formulations. They can also provide cost savings for both patients and payers. However, there are many times when the requested drug is clinically appropriate and should be approved. Implementing a PA helps ensure the safest and most cost-effective drug is being prescribed and utilized by the member; it can help to identify the “right” patient rather than being a barrier to access or care. However, that is not always easy to balance or achieve.

Many stakeholders agree that the PA process can sometimes be challenging, leading to negative experiences for patients (delays in treatment) and providers (high administrative burden). However, in a healthcare system with finite resources, utilization management tools are necessary to ensure healthcare dollars are spent wisely.

Reauthorization is most often used to assess how a patient is doing, if the drug is continuing to provide benefit for the condition it is treating, if the patient is experiencing any adverse effects, if the patient has completed any required testing/labs, if other alternatives should be considered, or if the continued treatment is warranted. It can also serve as a valuable tool to ensure appropriate use of current drug therapy and validate the ongoing financial investment in treatment.

Opportunities for Process Improvement

In our experience, many of the challenges associated with PAs lie in the execution of the process. Can additional efforts be considered to improve the efficiency of the process? Better electronic communication channels for providers could help ensure they send the right information the first time. Improved communication for patients could help them better understand alternative covered medications. Enhanced reviewer training could mitigate questions or confusion that lead to inappropriate approvals or delays.

While frustrations with the PA process are understandable, are there steps that can be taken to make it a little easier for all stakeholders?

Real-World Cost Implications

The value of utilization management can sometimes be lost due to negative impacts on patients and providers, but its importance shouldn’t be underestimated. When a prescriber increases the frequency of Stelara for Crohn’s disease from once every 8 weeks (the FDA-approved dosing) to once monthly, a patient will receive 6-7 additional doses each year, translating to $120,000-$140,000 additional annual costs. We observe examples of this prescribing pattern regularly with our clients and support prescriber education and the implementation of utilization management controls to reduce future increased dosing. Prescribers often don’t fully understand the cost implications of dosing changes. Yet with many patients now enrolled in consumer-directed high-deductible plans, these increases can significantly impact both patient finances and overall healthcare costs. What’s most important is ensuring each member receives the most clinically effective drug at the lowest net cost to provide optimal drug therapy benefit, a goal that requires communication and collaboration among all stakeholders.

Finding the Right Balance

We recognize the need for improvements to PA in its current form. Patients should have access to needed medications, and utilization management should not create barriers to care. We also recognize there are finite healthcare dollars and economic realities that must be considered. Though challenges remain, we are optimistic that collaboration can help improve education, communication, and processes to achieve optimal drug therapy benefits and outcomes for all patients.

For any questions about Optum’s PA announcement or other utilization management-related questions, please reach out to our expert clinical team!