Optum Rx to Modernize Pharmacy Payment Models

Rising prices set by pharmaceutical companies are causing pharmacies across the United States to pay more for many drugs, impacting their ability to maintain high-quality care for patients.

Effective immediately and with full implementation by January 2028, Optum Rx will align payment models more closely to the costs pharmacies may face due to manufacturer pricing actions. This change will positively impact Optum Rx non-affiliated network pharmacies, including the more than 24,000 independent, community pharmacies we serve. These cost-based payment models will also provide more consistently affordable experiences for consumers.

With this change, Optum Rx is addressing a legacy, industry-wide model that was originally designed to help promote the use of affordable generics. Effective generic adoption is now quite strong, and increasingly, more high-cost branded drugs are entering the market, raising costs for pharmacies. Addressing this imbalance will provide pharmacies with better financial means to stock more medicines, which will alleviate drug shortages, improve access to medications and deliver a better experience for consumers.

“Pharmacies and pharmacists provide important care to patients, and we recognize that increasing drug prices make it hard for them to afford needed medicines, especially independent and community pharmacies,” said Patrick Conway, M.D., chief executive officer of Optum Rx. “This move will help correct imbalances in how pharmacies are paid for brand and generic drugs and will ensure greater access to medicines for patients across the country.”

Epic Pharmacy Network, Inc. (EPN), a Pharmacy Services Administrative Organization representing over 1,000 independent pharmacies across the U.S., has partnered with Optum Rx to pursue a cost-based reimbursement model.

"Our pharmacists are critical partners in care and often the most consistent health care provider for the patients and communities they serve,” said Bretta Grinsteinner, EPN. “This move by Optum Rx is a significant step forward in changing the reimbursement model for our pharmacies, who continue to struggle with the rising costs of medications. EPN is committed to working alongside Optum Rx in their efforts to address reimbursement issues that plague pharmacies nationwide.”

In parallel, Optum Rx will similarly transition client arrangements - such as employer and health plan customers - to ensure transparency and greater alignment to drug costs. We have already started implementing these changes, with the goal of completing full implementation by January 1, 2028.

These changes build on our recent commitment to pass through 100% of drug rebate discounts negotiated with pharmaceutical manufacturers to clients by January 1, 2028. Combined, these moves make Optum Rx the first comprehensive, transparent pharmacy services company that passes through savings to its clients and consumers.

Supporting Pharmacies Across the U.S.

Optum Rx has been working to ensure pharmacies are paid fairly and offering solutions to improve operational efficiency and reduce administrative burden so they can spend more time caring for patients. Some of these efforts include:

• Reimbursing pharmacists for connecting their underserved patients to services that address basic needs such as food, nutrition, transportation, housing and baby supplies. Key areas of focus include maternal wellness and meeting health care needs in urban and rural communities where there are not many pharmacies.
• Supporting independent pharmacists by paying them for services such as counseling and medication management aimed at improving patient outcomes.
• Enhancing pharmacy digital capabilities to easily access claims and payment data, ease administrative burdens and manage revenue.
• Removing retroactive recoupment (“clawbacks”) for pharmacies.
• Offering predictive analytics and other tools to further reduce administrative burden and allow more time to focus on patient care.

About Optum

Optum is a leading information and technology-enabled health services business dedicated to helping make the health system work better for everyone. With more than 210,000 people worldwide, Optum delivers intelligent, integrated solutions that help to modernize the health system and improve overall population health. Optum is part of UnitedHealth Group. For more information, visit www.Optum.com.

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