Drastic value differences like this mean we have to make value-based judgments on drugs to help make prescription drugs more affordable for plan sponsors and members.
For us, drug value should support two goals:
- Help plan sponsors deliver the most clinically appropriate prescription benefit to their members.
- Help patients manage their care in the most cost-effective manner possible.
Lowest net cost in action
Optum offers a tightly integrated set of products and tools designed around the lowest net cost approach to help clients get the best value for their prescription drug benefit.
Let’s examine three examples: Formulary management, Vigilant Drug Program, and our biosimilars strategy. Each shows another way Optum Rx combines clinical value and lowest net cost to deliver improved care and lower costs.
Our rigorous, evidence-based clinical reviews are designed to ensure only the highest value new medications join our formularies.
1. Formulary management
Plan sponsors need a mechanism to translate low prices into effective medicines their members can use. Formularies play a key role.
In keeping with our value-based approach, every drug that makes its way onto one of our formularies must first pass through an extensive clinical review process.
Let’s look at formularies in more detail.
Clinical evidence leads
We use multiple teams of clinical experts to monitor important developments in drug therapy. For example, the Pharmacy and Therapeutics (P&T) Committee is comprised of independent clinical experts. Questions they will ask include:
- Does the drug have a unique therapeutic benefit?
- How does its safety and efficacy compare to other medications?
- Do its benefits outweigh its risks?
They determine which new medications are clinically meaningful, and deserve a spot on the formulary – before any cost considerations. Only then can the lowest net cost negotiation begin.
What select and premium formularies mean for you
Formularies are the backbone of an effective pharmacy benefit plan. Each formulary is designed to offer a specific balance between drug choice and cost savings:
- Select formulary: An open formulary that delivers savings by preferring more cost-effective products through tiering and utilization management strategies.
- Premium formulary: An open formulary that delivers savings through exclusion and utilization management strategies in select classes to maximize rebates.
- Premium Value formulary: A closed formulary that focuses on the lowest overall-net-cost alternatives without regard to rebates.
The Select and Premium formularies offer a choice of customized utilization management options, and ways to exclude certain drugs, for example, through the Optum Rx Vigilant Drug Program®. The Premium Value formulary is a self-contained product that comes packaged with our most aggressive management and drug exclusion tools.
The details differ, but each formulary model is designed to provide transparency, choice and customizable pharmacy benefit solutions. They help support the care quality, medication access, and cost considerations that are top of mind for every client and member.
2. Vigilant Drug Program
A troubling new trend involves new medications that carry hefty price tags, but offer little to no added clinical value. In many cases, there are generic alternatives available.
The Optum Rx Vigilant Drug Program® works by targeting high-cost brand and generic drugs that have lower-cost, clinically equivalent alternatives. Vigilant then excludes them from the formularies.
The Vigilant Drug Program comes as a modular design. So clients can decide which strategies best meet their unique needs based on member demographics, utilization patterns and value assessment.
The Clinical Duplicates drug list is one such module. It excludes drugs that are similar to existing approved drugs yet which offer little to no clinical benefit. In this example, Altoprev®, a branded cholesterol lowering drug, comes at a price that is nearly 1,200% higher than its clinical equivalent, the generic lovastatin: