Optum Rx to Modernize Pharmacy Payment Models
Optum Rx announces a major overhaul of pharmacy payment models to address rising drug costs and support pharmacies across the United States. The initiative, set for full implementation by January 2028, will align payment models more closely with pharmacy costs, particularly benefiting over 24,000 independent and community pharmacies in their network.
The company is transitioning from a legacy model originally designed to promote generic drug adoption to a cost-based reimbursement system that better reflects current market conditions, especially with high-cost branded drugs. This change aims to help pharmacies maintain medication inventory, reduce drug shortages, and improve patient access.
The reform includes key initiatives:
- 100% pass-through of drug rebate discounts to clients
- Reimbursement for pharmacists connecting underserved patients to essential services
- Payment for counseling and medication management services
- Enhanced digital capabilities for claims and payment management
- Elimination of retroactive recoupment ('clawbacks')
Optum Rx annuncia una revisione significativa dei modelli di pagamento per le farmacie per affrontare l'aumento dei costi dei farmaci e supportare le farmacie in tutto gli Stati Uniti. L'iniziativa, prevista per una piena attuazione entro gennaio 2028, allineerà i modelli di pagamento in modo più stretto con i costi delle farmacie, beneficiando in particolare oltre 24.000 farmacie indipendenti e comunitarie nella loro rete.
La società sta passando da un modello legacy originariamente progettato per promuovere l'adozione di farmaci generici a un sistema di rimborso basato sui costi che riflette meglio le attuali condizioni di mercato, specialmente per quanto riguarda i farmaci di marca ad alto costo. Questo cambiamento mira ad aiutare le farmacie a mantenere l'inventario di farmaci, ridurre le carenze e migliorare l'accesso dei pazienti.
La riforma include iniziative chiave:
- 100% di pass-through degli sconti sui rimborsi dei farmaci ai clienti
- Rimborso per i farmacisti che collegano i pazienti svantaggiati ai servizi essenziali
- Pagamento per servizi di consulenza e gestione dei farmaci
- Capacità digitali migliorate per la gestione di richieste e pagamenti
- Eliminazione del recupero retroattivo ('clawbacks')
Optum Rx anuncia una revisión importante de los modelos de pago de farmacias para abordar el aumento de los costos de los medicamentos y apoyar a las farmacias en los Estados Unidos. La iniciativa, prevista para una implementación completa para enero de 2028, alineará los modelos de pago más estrechamente con los costos de las farmacias, beneficiando especialmente a más de 24,000 farmacias independientes y comunitarias en su red.
La empresa está haciendo la transición de un modelo heredado originalmente diseñado para promover la adopción de medicamentos genéricos a un sistema de reembolso basado en costos que refleja mejor las condiciones actuales del mercado, especialmente con medicamentos de marca de alto costo. Este cambio tiene como objetivo ayudar a las farmacias a mantener el inventario de medicamentos, reducir las escaseces y mejorar el acceso de los pacientes.
La reforma incluye iniciativas clave:
- 100% de transferencia de descuentos de reembolsos de medicamentos a los clientes
- Reembolso para farmacéuticos que conectan a pacientes desatendidos con servicios esenciales
- Pago por servicios de asesoramiento y gestión de medicamentos
- Capacidades digitales mejoradas para la gestión de reclamaciones y pagos
- Eliminación de la recuperación retroactiva ('clawbacks')
Optum Rx는 약물 비용 상승에 대응하고 미국 전역의 약국을 지원하기 위한 약국 지불 모델의 대대적인 개편을 발표했습니다. 이 이니셔티브는 2028년 1월까지 완전 시행될 예정이며, 약국 비용과 지불 모델을 더 밀접하게 일치시켜, 특히 네트워크 내 24,000개 이상의 독립 및 지역 약국에 혜택을 줄 것입니다.
회사는 본래 일반 의약품 채택을 촉진하기 위해 설계된 레거시 모델에서 현재 시장 상황을 더 잘 반영하는 비용 기반 환급 시스템으로 전환하고 있습니다. 이 변화는 약국이 의약품 재고를 유지하고, 의약품 부족을 줄이며, 환자의 접근성을 향상시키는 데 도움을 주는 것을 목표로 합니다.
개혁에는 주요 이니셔티브가 포함됩니다:
- 약물 리베이트 할인에 대한 100% 패스스루
- 소외된 환자를 필수 서비스와 연결하는 약사에 대한 환급
- 상담 및 약물 관리 서비스에 대한 지불
- 청구 및 지불 관리를 위한 향상된 디지털 기능
- 소급 회수('클로백')의 제거
Optum Rx annonce une refonte majeure des modèles de paiement des pharmacies pour faire face à l'augmentation des coûts des médicaments et soutenir les pharmacies à travers les États-Unis. L'initiative, prévue pour une mise en œuvre complète d'ici janvier 2028, alignera les modèles de paiement plus étroitement sur les coûts des pharmacies, bénéficiant particulièrement à plus de 24 000 pharmacies indépendantes et communautaires dans son réseau.
L'entreprise passe d'un modèle hérité, conçu à l'origine pour promouvoir l'adoption des médicaments génériques, à un système de remboursement basé sur les coûts qui reflète mieux les conditions actuelles du marché, en particulier pour les médicaments de marque coûteux. Ce changement vise à aider les pharmacies à maintenir leur inventaire de médicaments, à réduire les pénuries de médicaments et à améliorer l'accès des patients.
La réforme comprend des initiatives clés :
- 100 % de transmission des remises sur les médicaments aux clients
- Remboursement pour les pharmaciens connectant les patients défavorisés à des services essentiels
- Paiement pour des services de conseil et de gestion des médicaments
- Capacités numériques améliorées pour la gestion des demandes et des paiements
- Élimination des récupérations rétroactives ('clawbacks')
Optum Rx kündigt eine umfassende Überarbeitung der Zahlungsmodelle für Apotheken an, um steigenden Arzneimittelkosten zu begegnen und Apotheken in den Vereinigten Staaten zu unterstützen. Die Initiative, die bis Januar 2028 vollständig umgesetzt werden soll, wird die Zahlungsmodelle enger an die Kosten der Apotheken anpassen und kommt insbesondere über 24.000 unabhängigen und kommunalen Apotheken in ihrem Netzwerk zugute.
Das Unternehmen wechselt von einem veralteten Modell, das ursprünglich zur Förderung der Annahme von Generika entwickelt wurde, zu einem kostenbasierten Erstattungssystem, das die aktuellen Marktbedingungen besser widerspiegelt, insbesondere bei hochpreisigen Markenmedikamenten. Diese Änderung soll den Apotheken helfen, den Arzneimittelbestand aufrechtzuerhalten, Arzneimittelengpässe zu reduzieren und den Zugang der Patienten zu verbessern.
Die Reform umfasst wichtige Initiativen:
- 100% Durchleitung von Arzneimittelrabattvergünstigungen an die Kunden
- Erstattung für Apotheker, die unterversorgte Patienten mit wichtigen Dienstleistungen verbinden
- Bezahlung für Beratungs- und Arzneimittelmanagementdienste
- Verbesserte digitale Möglichkeiten für die Verwaltung von Ansprüchen und Zahlungen
- Eliminierung der rückwirkenden Rückforderung ('clawbacks')
- Implementation of cost-based payment models to better reflect actual pharmacy expenses
- 100% pass-through of drug rebate discounts to clients
- Elimination of retroactive recoupment (clawbacks) improving pharmacy cash flow
- New revenue streams for pharmacies through paid counseling and medication management services
- Enhanced digital capabilities reducing operational costs
- Extended implementation timeline until January 2028 delays immediate relief
- Transition costs and potential operational disruptions during implementation period
Insights
Optum Rx's announcement marks a significant strategic shift in pharmacy benefit management that addresses fundamental industry payment imbalances. By aligning reimbursements more closely with actual drug costs through 2028, Optum is tackling a critical pain point for independent pharmacies struggling with high-cost branded medications.
This move serves multiple strategic objectives: enhancing network stability by supporting community pharmacies financially, potentially reducing medication access issues caused by pharmacy inventory constraints, and positioning Optum Rx as an industry leader in transparency. The parallel commitment to pass through 100% of drug rebate discounts to clients represents a structural change to traditional PBM revenue models where rebate retention has historically been a profit center.
The gradual implementation through 2028 gives UnitedHealth time to adapt its business model while maintaining financial stability. This transformation addresses mounting scrutiny of PBM practices from regulators and legislators, potentially providing UnitedHealth a competitive advantage as pharmacy benefit management faces increased transparency demands.
The initiative fits within UnitedHealth's broader strategy of vertical integration and value-based care, creating stronger relationships with pharmacy partners while potentially improving patient outcomes through enhanced medication access. While near-term margin pressure is possible, the long-term strategic positioning and regulatory risk mitigation likely outweigh short-term financial considerations.
Optum Rx's pharmacy payment model overhaul represents a material evolution in how the third-largest PBM in America approaches drug economics. This isn't merely operational tinkering - it's reconstructing fundamental payment structures that have defined the industry for decades.
The financial implications are nuanced. By more closely aligning payments with pharmacy acquisition costs, Optum is effectively redistributing value within the pharmaceutical supply chain. The commitment to pass through 100% of manufacturer rebates by 2028 potentially sacrifices a traditional PBM revenue stream, but this should be viewed alongside several counterbalancing factors:
First, the extended implementation timeline allows for managed financial adaptation. Second, strengthening the pharmacy network, particularly the 24,000+ independent pharmacies, protects market share and enhances Optum's value proposition to clients. Third, this positions UnitedHealth advantageously amid increasing regulatory scrutiny of PBM practices.
The initiative also demonstrates forward-thinking economics regarding pharmacy sustainability. By addressing systemic underpayment issues that have threatened independent pharmacy viability, Optum strengthens its network integrity while potentially reducing medication access barriers. Additional value-adding initiatives like reimbursing pharmacists for connecting underserved patients to services creates network differentiation while supporting population health objectives.
This transformation signals UnitedHealth's recognition that the PBM business model must evolve beyond traditional spread pricing and rebate retention toward more sustainable, transparent approaches that maintain viability across the pharmaceutical care continuum.
Rising prices set by pharmaceutical companies are causing pharmacies across
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
"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
Supporting Pharmacies Across the
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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Media Contact: newsroom@optum.com
Source: Optum
FAQ
When will Optum Rx complete the implementation of its new pharmacy payment model?
How many independent pharmacies will benefit from Optum Rx's new payment model?
What changes is Optum Rx making to drug rebate discounts?
What additional services will Optum Rx reimburse pharmacists for?
How is Optum Rx addressing pharmacy payment challenges?
