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In contrast, when pharmacy and medical benefits are integrated, the carrier and providers have a clearer view into a member’s health status and whole-person health needs. This can enable faster and more informed clinical decisions, that may result in better health outcomes, lower costs and a more seamless and connected experience overall.

“The power of UnitedHealthcare is the data-driven, embedded decision-making that can occur when pharmacy and medical benefits are integrated,” says Matthew Vesledahl, chief affordability officer for UnitedHealthcare Employer & Individual.

While the advantages of benefit integration are largely well understood in the market, cross-benefit drug management can add additional value, which includes the process of:

• Analyzing the efficacy, financial impact and administration experience of specific drugs
• Determining whether a medication should be covered under a member’s medical or pharmacy benefit
• Managing care across each benefit to help ensure members are directed to lower-cost medications and care settings when clinically appropriate, regardless of which benefit may be covering treatment

Aside from cost, the way a medication is administered often determines which benefit will cover it. For example, medications in pill form or self-injectables are typically covered by the pharmacy benefit, whereas infusions are typically covered by the medical benefit.

Cross-benefit drug management becomes even more impactful when applied to specialty medications. Used to treat complex or rare chronic conditions, these medications typically account for more than 60% of an employer’s total drug spend,⁵ with more than half of that spend under the medical benefit.⁶

Consider Neulasta®, a drug used to treat low white blood cell count (neutropenia) — a common side effect of cancer treatment:

Step 1: The UnitedHealthcare Prescription Drug List (PDL) Management Committee analyzes the cost and advantages of Neulasta under both the pharmacy and medical benefits.

Step 2: Upon review, the committee finds that the cost of Neulasta Onpro is lower under the medical benefit when administered at a provider’s office, saving $1,600 per claim on average, compared to pharmacy benefit coverage, according to UnitedHealthcare 2023 claims data.

Step 3: Finally, the committee checks to ensure the member’s experience isn’t sacrificed for that lower cost. Market feedback reveals that members tend to appreciate the fact that the Neulasta Onpro device can be inserted by a provider during their chemotherapy session, eliminating the need for additional appointments or self-administration of the drug, which may be daunting for some patients.

Without this thorough cross-benefit drug management approach, the employee and their employer may have had to pay more, and the employee may have had to self-administer the drug or schedule additional appointments, potentially taking time away from work.

Cross-benefit drug management shows how an integrated approach with UnitedHealthcare medical and pharmacy may ultimately lead to:

If benefits are integrated, providers and carriers can more proactively guide members to lower-cost drug alternatives and care settings, when clinically appropriate. This includes determining whether a drug or treatment may be more cost-effectively covered and managed under the medical or pharmacy benefit through the cross-benefit drug management process.

Did you know? Up to $10 per member per month (PMPM) average medical savings are guaranteed with UnitedHealthcare Pharmacy¹⁰

When data and coverage information can be viewed and shared across a member’s medical and pharmacy benefits, the carrier and providers are able to see a more complete picture of whole-person health needs. As a result, they may identify and engage members more quickly and make more informed care decisions with the goal of better health outcomes and lower costs.

Did you know? Referrals to clinical programs occur up to 44 days sooner with integrated benefits, in part due to real-time pharmacy data enabling faster identification of members in need¹¹

Because providers have greater visibility into a member’s medical and pharmacy coverage and utilization when those benefits are integrated, care can be more coordinated and more seamless. In addition, members have a single view and access point into their medical and pharmacy benefits information through digital tools like the UnitedHealthcare® app and myuhc.com®.

Did you know? Nearly 37% of prior authorization requests are bypassed when UnitedHealthcare medical and pharmacy benefits are integrated¹²