Concerns about the rising cost burden of prescription medications represent a rare area of agreement across the health care sector.
In a recent study of plan sponsors, 90% said high drug prices are a threat to the affordability of employer-provided coverage.1 High-cost drugs also present affordability concerns for patients. Even though more than 90% of Americans have health insurance, half say they are only one illness away from financial trouble.2
High-cost drugs that offer little to no added clinical value over existing, less expensive alternatives are one of the leading drivers of rising costs. These drugs continue to enter the market and can cost hundreds as times as much as clinically appropriate alternatives.
The Optum Rx® Vigilant Drug Program™ addresses the challenge caused by these high-cost, low-value drugs. The program uses advanced analytics and dedicated market surveillance to identify these drugs. It then removes wasteful spending by shifting utilization to lower-cost drugs through exclusions.
How it works
The program uses advanced analytics and dedicated market surveillance to identify these drugs. Participating plan sponsors can then opt to exclude them from pharmacy benefits. As the chart below indicates, the Vigilant Drug Program is modular and makes use of several clinical quality and cost-savings strategies to achieve robust overall per member per month (PMPM) savings.
The program includes clinical quality strategies to drive clinical appropriateness and cost savings.
- New drugs to market strategy — Temporarily excludes newly launched products until they can be formally reviewed by the Optum Rx National Pharmacy & Therapeutics (P&T) Committee. This program is a standard component of our Premium Formulary. This helps minimize member disruption and decrease financial risk until P&T review is completed. These drugs accounted for 9% of PMPM savings in 2020.
- Clinical duplicates strategy — Excludes newer, more costly medications that offer no clinical advantage over existing medications with similar chemical composition and possible generic options. Examples include unique dosage forms, combinations of two or more available medications, unique strengths, certain delivery devices and multiple product kits/packages. These drugs accounted for 41% of PMPM savings.
- Non-essential strategy — Excludes select high-cost, non-FDA-approved products or those deemed unnecessary. Encourages use of lower-cost, FDA-approved options with established safety and effectiveness for the same condition(s). These drugs accounted for 32% of PMPM savings.
The program also includes cost-saving strategies to promote use of clinically equivalent, lower-cost options.
- High-cost brands with generics — Excludes select high-cost brand products when a lower-cost, therapeutically interchangeable generic product is available. This accounted for 4% of PMPM savings.
- High-cost generics — Excludes high-cost generics when lower-cost alternatives are available with the same active ingredients or belong to the same drug class. This accounted for 14% of PMPM savings.
As high-cost medications continue to enter the market, the Vigilant Drug Program detects them and identifies alternatives. Participating plan sponsors can then opt to exclude them from pharmacy benefits.
Since it launched, the Vigilant Drug Program has saved plan sponsors a total of $1.5 billion.3 In 2020 alone, savings reached $754.3 million. As the number of medications covered by the program continues to grow, so do the savings. In 2020, the per member per month (PMPM) savings rose to $4.50, a 3% increase over 2019.4