Optum Rx Ends Reauthorization for Many Chronic Disease Drugs

Optum Rx is eliminating reauthorization on almost 70 drugs for chronic diseases, which the company said is equal to more than 10% of overall pharmacy prior authorizations. The PBM will work with physicians and pharmacists to expand the list over time.

Optum Rx used the following criteria:

• No added safety risk to patients
• Diagnosis established and long-term condition
• Requires chronic treatment
• Long-term drug effectiveness is established
• Dose requirements likely to remain constant
• Alternative therapy has been considered

"Once the initial prior authorization has been approved, the drugs in scope are no longer subject to reauthorization," a spokesperson said. "Prior authorization is an important checkpoint helping patients access coverage for safe, effective care, supported by the most up-to-date clinical guidelines. As part of an ongoing program, we are removing up to 25% of reauthorizations to enhance the patient experience and the continuity of care for chronic conditions. Reauthorizations are necessary for certain drugs for chronic conditions that need monitoring for effectiveness and/or dose adjustments."

The drugs that have had the reauthorization removed include:

• Cholesterol-lowering drugs: Praluent, Repatha, Leqvio, Juxtapid, Lovaza, Vascepa, Nexletol, Nexlizet
• Idiopathic pulmonary fibrosis therapies: Esbriet, Ofev
• Pulmonary arterial hypertension drugs: Revatio, Liqrev, Uptravi, Tracleer, Letairis, Adcirca, Alyq, Tadliq, Opsumit, Veletri, Flolan, Orenitram, Remodulin, Tyvaso, Adempas, Ventavis, Opsynvi, Winrevair
• Cystic fibrosis drugs: Kalydeco, Trikafta, Symdeko, Orkambi, Pulmozyme, Alyftrek
• Multiple sclerosis drugs: Mavenclad, Plegridy, Lemtrada, Rebif, Ponvory, Extavia, Kesimpta, Ocrevus/Zenovo, Mayzent, Betaseron, Copaxone, Glatopa, glatiramer acetate, Aubagio, Bafiertam, Avonex, Vumerity, Mitoxantrone, Ampyra, Gilenya, Tecfidera, Tysabri, Zeposia, Tascenso ODT, Briumvi
• Migraine drugs: Aimovig, Ajovy, Emgality, Qulipta, Nurtec, Ubrelvy, Vyepti, Zavzpret

“Optum Rx is taking meaningful steps to simplify patient experiences and increase access to critical medications,” said Patrick Conway, M.D., chief executive officer, Optum Rx, said in a news release. “These changes mean easier access to medications for consumers, less work for pharmacists and physicians and a simplified system focused on clinical quality.”

At the same time, Optum Rx defended prior authorizations as necessary ensuring safe, appropriate, evidence-supported use of drugs.

Related: UnitedHealth Group's 2024 Revenue Grows to Reach $400.3 Billion

Optum Rx, the pharmacy benefit manager of UnitedHealth Group, saw revenue in 2024 increase by 15%, according to the company’s earnings release in January 2025. The number of adjusted scripts grew to 1.62 billion, compared with 1.54 billion in 2023. In a call with investors in January, Andrew Witty, CEO of UnitedHealth Group, vowed to reduce the prior authorization burden and to work on speeding up turnaround times for procedures and services in Medicare Advantage plans.

The healthcare insurance industry has faced scrutiny over its handling of prior authorizations and claims denials even before the murder of UnitedHealthcare CEO Brian Thompson on Dec. 4, 2024, shocked the industry. Last year, the Senate Permanent Subcommittee on Investigations released a report highlighting how AI was being used by insurers to evaluate claims in Medicare Advantage.

UnitedHealth has since been working to address the challenges physicians and patients face. Within OptumRx, the company introduced in October 2024 the PreCheck Prior Authorization program to help speed authorizations.