UnitedHealth Group engaged Analysis Group to independently assess Optum Rx’s approach to prescription drug manufacturer discounts in its role as pharmacy benefits manager (PBM). This process included thorough document reviews and interviews with personnel directly involved in the discount administration process.
Analysis Group concluded that Optum Rx has built a robust and well-structured governance framework, with a comprehensive set of controls for drug manufacturer discounts and their disbursement to clients that strengthen the accuracy of its processes. They identified 25 controls that the organization has put in place to ensure accurate manufacturer discount collection and disbursement, minimize errors and support audits. These controls include standardized documentation, layered reviews, automated systems, and monitoring, all aligned with widely recognized industry standards for compliance and risk management. Analysis Group noted, “as with any comprehensive and sophisticated program, opportunities remain to further enhance efficiency and oversight,” and provided a series of technical recommendations including, among others, conducting a review of client-initiated audits and assessing opportunities for additional client reporting.
Optum Rx will further consolidate and streamline policies, procedures and job aids for administrating manufacturer discounts. These actions include strengthening escalation protocols for non-payment and disputes, enhancing reporting clarity over discount exclusions and implementing automation for high-volume, low-complexity processes to improve efficiency.
PBMs such as Optum Rx are hired by clients to negotiate with drug manufacturers to ensure their members have access to the lowest possible price of a drug – these negotiations lead to discounts that PBMs pass through to clients based on contract terms.
Since only drug manufacturers have the power to set drug prices, PBMs play a critical role in helping combat high drug costs via discount negotiations.
UnitedHealth Group’s PBM Optum Rx was the first PBM to commit to passing through 100% of negotiated discounts to its clients by 2028. This commitment is part of Optum Rx’s broader effort to transform pharmacy benefits by putting affordable drug access first, creating new models to pass savings to consumers, supporting local pharmacies and pushing back against pharmaceutical companies’ pricing power.