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Creating a “next generation” commercial formulary to tackle rising drug costs

The increasing cost of drugs is a primary concern for our clients. That’s why OptumRx has created a new evidence-based formulary designed to advance health care’s triple aim: clinical quality, cost-effectiveness and consumer affordability. The Premium Value formulary maximizes cost savings by focusing on a limited number of clinically proven therapies for any given condition. Thus, clients can expect greater net savings due to ingredient cost savings and the clinically appropriate use of brand or generic medications for all conditions.

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This Q&A with OptumRx SVP of clinical & formulary services Savitha Vivian explains what considerations went into the creation of the Premium Value formulary and how it differs from traditional approaches. For a deeper dive, listen to this on-demand webinar to learn more about how the OptumRx Premium Value model provides value to clients and members.

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Building long-term partnerships with clients

OptumRx knows that providing strategic oversight is key to clients manage prescription medication costs. See how one nonprofit employer partnered with OptumRx under a coalition pricing arrangement that provided greater negotiating power as well as access to dedicated account teams something many small- or mid-size employers don’t typically experience. Employing comprehensive utilization management programs as well as additional clinical and maintenance programs lower costs, the employer was able to provide its employees with access to the most effective, affordable medications available and improve health outcomes, while reducing potential for financial waste. As a result of this partnership with OptumRx, the client saved $938,000 in one year as they worked to fulfill their mission.

Young life case study

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Combatting pricey, brand-name medications that offer little to no added clinical value

The rising prices of medications set by drug manufacturers is leading to financial burdens for both plan sponsors and members. As new medications enter the market, OptumRx has observed a troubling new trend that contributes to the rising cost of health care: an influx of therapeutically equivalent brand drugs that carry hefty price tags but offer little to no added clinical value. This drug pricing spotlight report examines how some drug manufacturers have launched brand-name prenatal vitamins that include similar combinations of vitamins and minerals but priced significantly higher than preexisting, clinically comparable and generic alternatives. The report also explains how OptumRx Through advanced analytics, we routinely monitor the potential impact of these types of products at a client level and proactively advise and deploy strategies to protect against their negative financial impact without compromising quality of patient care.

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A targeted strategy to help control growing orphan drug costs

New orphan drugs bring hope for the 30 million Americans who are affected by a rare disease, but they come at a cost with treatments being up to $750,000/year. We’ve addressed this challenge by evaluating over 2,000 ultra-high cost orphan drugs to identify which present the greatest opportunity for personalized clinical support and cost savings.

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In this short video, you can hear directly from OptumRx chief pharmacy officer, David Calabrese, on how we're tackling these complex orphan conditions while ensuring cost efficiency for our clients and affordability for our members.

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Orphan drugs: Support for complex treatments [video]

An orphan drug is designated by the FDA to treat a rare condition. In the United States that typically is a condition that affects less than 200,000 people nationally. Today there are about 7,000 orphan diseases that have been identified and about 30 million people in the United States are affected by one of these diseases and sadly, probably about half of those are kids. The orphan drug market is a hot market because this is where the pharmaceutical industry is investing most heavily in terms of research and development. Because a variety of incentives that have been bestowed upon them by the FDA. It's an area where they have very limited barriers to entry and an ability to launch products at very exorbitant price tags. We recently set a new mark in the industry where we had a product that was introduced to market, with a price tag of 2.1 million dollars. It's a challenge and that's what the industry is grappling with right now. That's why we're investing as much time and energy to try and get our arms around this to help our clients, to help the members to ensure that those drugs are made more affordable. And that any safety issues, tolerability issues, are not outweighing any potential benefits that patient may be receiving. The OptumRx Orphan Drug program is a program designed to ensure that patients who are receiving these therapies, caregivers who are caring for these patients and the providers who are writing for these medications, are supported in a much more robust fashion. At OptumRx we conduct what's called a comprehensive medication review. To share that information and to advise the doctor, you know when appropriate, if adjustments need to be made, or and in some instances when it may be best to discontinue therapy, you know because not every patient is going to respond to these drugs. Our job is first and foremost to care for the member, particularly in this case, members with rare diseases, but also we have a job to do in terms of driving cost efficiency for both the client and affordability for the member.

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