More transparency and simplicity: Setting the standard in pharmacy care
Optum Rx’s changes to pharmacy payment models and reauthorizations are making pharmacy care more transparent and easier.
Reducing prior authorizations
To make drugs more affordable and easier to access for consumers, we are eliminating up to 25% of reauthorizations — more than 10% of overall pharmacy prior authorizations — for a list of 80 drugs that will be reviewed and expanded over time.
This will help keep patients on their medications, reduce workload for physicians and pharmacists and reduce costs for clients who will no longer have to pay administrative fees for unnecessary reauthorizations.
“Optum Rx is taking meaningful steps to make the prior authorization experience better for those we serve. These changes mean easier access to medications for consumers, less work for pharmacists and physicians, and a simplified system focused on clinical quality.”
Patrick Conway, M.D. | chief executive officer, Optum Rx
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.
Pharmacies will now have the financial means to stock more medicines, which helps prevent drug shortages and improve access for everyone. Optum Rx will also transition our client arrangements, such as employers and health plans, to ensure transparency and greater alignment to drug costs. 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.
"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 life-saving 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 $58.