Optum Fusion Program Explainer
Specialty medication management is a complex and growing challenge. New and expensive specialty treatments, and increase in utilization of in-market therapies are dramatically increasing costs. And with specialty treatments being under both the pharmacy and medical benefit it leaves plan sponsors with limited ability to dynamically analyze data and manage specialty treatments across both benefits.
Prescribers are challenged with ever changing guidelines, medical policies, prior authorization requirements, benefit coverage and site of service requirements, which makes it hard to determine the highest-quality treatment option at the lowest cost. Specialty patients typically are on multiple medications, seeing multiple providers and have coverage under both their medical and pharmacy benefit, and while they may not realize it, their experience is the direct result of the difficulty of navigating the complexities of specialty medication management. To address these challenges, we are proud to offer Optum Specialty Fusion™, an industry first benefit agnostic specialty management solution. This solution combines Optum data and analytics across both the medical and pharmacy benefit with known value of all available management strategies agnostic to benefit to recommend the most clinically and financially appropriate specialty treatment options.
When a prescriber submits a request through the portal, Specialty Fusion first assists through a display of the appropriate clinical options and then applies available management strategies to assess financial factors like available rebates, lower cost site of care, and manufacturer assistance programs. Optum Specialty Fusion can then provide recommendation for treatment options and details as to coverage. Plus, with full integration with both benefits providers can complete the prior authorization of the medication on either benefit.
Let’s compare a real example using current in-market solutions versus Specialty Fusion. With current in-market solutions that lack full integration the provider seeks a prior authorization request for Rheumatoid Arthritis for coverage on the patient’s medical benefit. The solution may identify an alternative medication, but the request would ultimately only be approved on the medical benefit.
With Optum Specialty Fusion, the providers enter a request for treatment. The solution analyzes all value levers on both medical and pharmacy benefits, taking into account the most clinically appropriate treatments, medical and pharmacy benefit options including site of care, pharmacy or medical rebates, network options, manufacturer assistance and more that drive to the lowest cost of care. This occurs in real time allowing for a streamlined experience in decisioning and prior authorization. This allows Optum Specialty Fusion to assist the prescriber in selection of the clinically appropriate and lowest cost options delivering even more value to plan sponsors and in this case, Specialty Fusion finds an option covered on the pharmacy benefit costing $700 less than current in-market solutions. Using this unique real-time decisioning process, Optum can drive incremental value of up to $15 per member per month savings across both medical and pharmacy spend.
Plan sponsors also benefit from an incredible wealth of real-time specialty data so they can better understand their specialty spend, partner better with providers, and improve their specialty strategy over time. The platform reduces administrative hassle for providers and works quickly to secure real-time treatment approval. And, Specialty Fusion improves the patient experience too. Medical and pharmacy treatment start times are aligned, helping patients start therapy faster. Optum Specialty Fusion helping make making the health system work better for everyone.
Faster time to therapy for patients1
Up to $15 PMPM
Medical and pharmacy savings2
A new way to manage specialty drug spend
Specialty medications are costly, hard to manage and are often covered under both medical and pharmacy benefits. In addition, the volume of new drugs make it difficult for providers to keep up with the best treatment options and plan sponsors struggle to control costs.
Specialty Fusion dynamically analyzes dozens of value levers on both medical and pharmacy benefits to recommend the optimal benefit, site of care and drug choice based on clinical and financial factors resulting in improved patient experiences at a lower cost of care.
- Electronic PA at the point of prescribing; AMA Survey 2019 (https://www.covermymeds.com/main/medication-access-report/electronic-prior-authorization/)
- Optum Internal Analysis. Actual savings potential will vary based on plan sponsors who have low to highly managed programs in place.
- Provider NPS based on Sept. 2020 Optum Book of Business analysis. Auto-approval, denial and turn around time Aug. 2020 – Oct. 2020 CGP Book of Business analysis