Data and AI transform pharmacy care services


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Powerful new technologies like artificial intelligence (AI) are letting all kinds of organizations gather, sort and interpret unprecedented amounts of data. These intelligent tools promise to revolutionize whole segments of the health care economy, enabling services that are faster, more efficient and far more personalized.

Data-enabled high-touch/high-impact engagement with members

OptumRx® member advocates field all sorts of questions from members, often for common issues like a lost identification card or the location of a local network pharmacy. Using an approach called Next Best Action, OptumRx leverages ongoing advances in predictive analytic technology to drive a personalized experience for every member who calls.

Advocates look further than the initial inquiry. They treat the calls as opportunities to personally connect with each member on health and savings opportunities, like condition management, pharmacist medication consults, lower-cost drug alternatives, wellness programs and behavioral services.

The Next Best Action recommendation engine achieves this by constructing a highly personalized view of each member. Backed by OptumIQ™, the Next Best Action model integrates individual attributes such as medical and pharmacy claims history, demographic information and whether they have used any health and wellness programs. These are combined with detailed insight into the member’s exact benefit information, and all of this is filtered through a sophisticated set of rules governing clinical quality and clinical best practice.

After addressing the member’s original reason for calling, the Next Best Action tool automatically populates the member representative’s dashboard screen with care improvement options personalized for that member. Each option represents an opportunity to save money or use program benefits available under the member’s benefit plan.

Personalized patient data can determine their next best action


Employing behavioral economics principles, Next Best Action uses predictive analytics to rank how likely it is that someone will accept a given engagement option, for example, a smoking cessation program.

While an advocate might offer the member several options for better health, the best course of action for that individual, as determined by the model, is listed first.

The accuracy of these predictions has resulted in members accepting the engagement option over 60% of the time. That’s a rate 159% higher than before the team was applying AI.

The result is better health outcomes and lower overall medical costs for clients. ­

Streamlining the prescription process

Another tool makes use of synchronized data to simplify and streamline one of the most common doctor-patient encounters: writing a prescription.

Increasingly, doctors are treating patients who could benefit from one of today’s advanced medicines. But these prescribing decisions are not always simple:

  • The newest drugs are often very expensive.
  • Many new biologic drugs can be highly targeted; aimed only at certain types of a disease, or only at people with precisely defined genetic features.
  • Benefit plan coverage rules are complicated. Until now, doctors have rarely had detailed insight into how they work for at the individual member level.

A new tool, PreCheck MyScript®, makes this process work better for doctors and patients. It seamlessly integrates with physicians’ electronic medical record (EMR) systems and provides real-time, member-specific benefit information at the time and place of patient care.

PreCheck MyScript also gives physicians information about whether a medication is covered, how much it will cost and if there is a clinically suitable alternative that will save the patient money. This allows physicians to compare recommended treatment options side by side. If prior authorization is required, physicians can process that right in the EMR, with immediate approval in most cases.

PreCheck MyScript brings together highly diverse data streams into one simple-to-use tool. The ability to combine pharmacy and coverage data can make the difference between a member who has immediate access to their prescribed medications and one who is turned away at the pharmacy counter.


Since OptumRx launched PreCheck MyScript in 2017, more than 1.8 million patients have filled their prescriptions faster and at lower costs. Results to date include:

  • One out of five transactions with a recommended alternative resulted in a drug change or lower-cost alternative, delivering significant cost savings for patients and payers.
  • More than 30% of PreCheck MyScript prior authorizations were initiated electronically—or were avoided altogether—as a result of access to real-time patient-specific benefit information.

Improving the call center experience

OptumRx has also leveraged artificial intelligence and machine learning (AI/ML) capabilities to improve call flow and match callers with the agents best-suited to answer their specific question or issue.

The AI software is continuously analyzing the data for each outcome, relative to both the types of questions and the performance of the OptumRx representatives. In effect, the system is learning to improve itself, with no human interaction. This approach allows for continual process improvements which eliminate unnecessary tasks for call center agents and empower them with more relevant data to address a caller’s need earlier in the call. It also steers customers with simple or transactional inquiries to self-service channels, leaving agents to focus on the most complex problems.

The result is reduced average hold times, increased first-time resolutions and a better overall member experience. This increase in customer satisfaction also improves the ability of OptumRx to promote higher medication adherence rates and better health for millions of members with chronic conditions.

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This article is directed solely to its intended audience about important developments affecting the pharmacy benefits business. It is not intended to promote the use of any drug mentioned in the article and neither the author nor OptumRx has accepted any form of compensation for the preparation or distribution of this article.

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