More transparency and simplicity: Setting the standard in pharmacy care
Optum Rx’s changes to pharmacy payment models, increased brand drug reimbursement and reduced reauthorizations are making pharmacy care more transparent and easier. These initiatives build on our commitment to pass on all drug rebate discounts to clients by Jan. 1, 2028. Combined, these moves make Optum Rx the first comprehensive, transparent pharmacy services company that passes through savings to its clients and consumers.
Reducing overall prior authorizations
To make drugs more affordable and easier to access for patients, we eliminate 25% of reauthorizations — more than 10% of overall pharmacy prior authorizations — for a list of 180 chronic condition drugs that will continue to be reviewed and expanded over time.
This will help keep patients on their medications, reduce administrative workload for physicians and pharmacists and reduce costs for clients who will no longer have to pay administrative fees for unnecessary reauthorizations.
Learn more about our latest prior authorization changes here, here and here.
“At Optum Rx, we are committed to simplifying the pharmacy experience and improving access to essential medications. By making the prior authorization experience better, we are helping patients stay on their medications, easing the workload on physicians and pharmacists and reducing costs for those we serve. These initiatives reinforce our commitment to transparency, clinical quality and affordability, and enable us to help make the health system work better for everyone.”
Jon Mahrt | Chief Executive Officer of Optum Rx and Chief Growth Officer of Optum
Modernizing pharmacy payment models
Pharmacies across the United States are paying more for many drugs due to rising prices set by pharmaceutical companies. To help pharmacies increase their ability to maintain high-quality care for patients, Optum Rx will align payment models more closely to the costs pharmacies may face due to manufacturer pricing actions. This change will help more than 24,000 independent community pharmacies in Optum Rx's network and ensure consumers have more consistent prices for drugs.
Optum Rx also increased reimbursement minimums on brand drugs for approximately 2,300 community and independent pharmacies – those not affiliated with a pharmacy services administrative organization, chain or other entity – to support their long-term sustainability, especially those serving vulnerable communities, and the patients they serve.
Pharmacies will now have the financial means to stock more medicines, which helps prevent drug shortages and improve access for everyone. Learn more about the changes to pharmacy payment models here and our increased brand drug reimbursement here.
"Our pharmacists are critical partners in care and often the most consistent health care provider for the patients and communities they serve. 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 of addressing reimbursement issues that plague pharmacies nationwide.”
- Bretta Grinsteinner |
Epic Pharmacy Network, Inc.
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.
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 (“claw backs”) for pharmacies.
Offering predictive analytics and other tools to further reduce administrative burden and allow more time to focus on patient care.
Lowering drug costs
While our model helps rein in the large price variation between brand and generic drugs, we continue to take bold steps to tackle high drug prices through negotiation and cost-cutting tools such as:
- Optum financial assistance programs, including Optum Savings IQ: Helped save consumers $1.3 billion in 2024, reducing out-of-pocket costs to an average of $5 for eligible specialty patients.
- Our Critical Drug Affordability List: Caps out-of-pocket costs for more than 290 lifesaving medications, with average costs less than $18 per month for insulin and $5 for most drugs.
- Price Edge: A digital price comparison tool that generated $224 million in consumer savings, averaging $50 per person.
- PreCheck MyScript: Real-time tool that ensures consumers get the best price for their medications, saving $119 per prescription fill and $266 for clients.
- Proactive Savings Alerts: Notifies consumers of savings opportunities, averaging $42 per prescription.
- MyScript Finder: Shows medication prices and cheaper alternatives, saving users an average of $90.