Optum Rx Changes How Pharmacies Are Reimbursed

Optum Rx is implementing a new program to align payment models more closely to the costs pharmacies incur. This change is effective immediately, and Optum Rx expects full implementation by January 2028. The change in reimbursement will impact Optum Rx non-affiliated network pharmacies, including the more than 24,000 independent, community pharmacies, according to the company.

In a news release, Optum Rx said it is also transitioning employer and health plan customers to this new model to better align drug costs. The goal is for full implementation by Jan. 1, 2028.

“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,” Patrick Conway, M.D., chief executive officer of Optum Rx, said in a news release.

Epic Pharmacy Network (EPN), a pharmacy services administrative organization representing more than 1,000 independent pharmacies across the United States, has partnered with Optum Rx to pursue a cost-based reimbursement model.

An Optum Rx spokesperson said the cost-based program uses an internal algorithm that leverages multiple available industry data sources, such as NADAC and PAC, to inform reimbursement. National Average Drug Acquisition Costs (NADAC) is the approximate invoice price pharmacies pay for medications in the United States. The Predictive Acquisition Cost (PAC) model is an estimation of costs compared with average wholesale price (AWP).

The National Community Pharmacists Association (NCPA) in a statement that they “welcome a new approach to prescription reimbursement that fairly pays pharmacists for their dispensing and patient care services; we would need to see the details of their plan before we can assess it. NCPA remains hopeful that at least one of the Big 3 PBMs wants to address the prescription payment issues that affect pharmacies’ ability to stay open and care for their patients.

“If this is a good-faith effort, it would be a good first step in reimbursing all independent pharmacies for the actual cost of acquiring drugs, plus the cost of counseling patients, serving patients, inventory, supplies, and other overhead,” the statement continued. “Otherwise, this will be another cost-shifting gambit that will leave independent pharmacies in the same position. In either event, federal PBM reform remains essential to provide stability, transparency, and predictability for patients and pharmacies.”

Antonio Ciaccia

In a LinkedIn post, Antonio Ciaccia, president of 3 Axis Advisors, commented on Optum Rx’s effort, saying, “Lots of PBM press releases promising industry changes as of late, and while trust should be earned through data and results, the words on paper demonstrate an acknowledgment of past misaligned approaches to pricing that have led them to the public frying pan.”

Optum Rx officials said in the news release that the PBM is working to improve pharmacy efforts. In 2023, it removed retroactive “clawback” fees from pharmacies and in January 2024 began providing reimbursement for pharmacists in some areas to provide counseling and medication management and for connecting patients with community services.

Related: New PBM Reform Bill Would End Spread Pricing at Medicaid Pharmacies

Earlier this month, senators introduced a bipartisan bill that would limit PBMs’ spread pricing at pharmacies used by Medicaid beneficiaries. Senators Peter Welch, a Democrat from Vermont; Roger Marshall, a Republican from Kansas; Mark Warner, a Democrat from Virginia; and Bill Cassidy, a Republican from Louisiana, have introduced the Protecting Pharmacies in Medicaid Act, which would require Medicaid’s payments to PBMs to be passed directly to pharmacies, excluding administrative fees.

Related: Optum Rx Ends Reauthorization for Many Chronic Disease Drugs

Yesterday, Optum Rx announced it is eliminating reauthorization on almost 70 drugs for chronic diseases, which the company said is equal to more than 10% of overall pharmacy prior authorizations. The PBM will work with physicians and pharmacists to expand the list over time.

Optum Rx, the pharmacy benefit manager of UnitedHealth Group, saw revenue in 2024 increase by 15%, according to the company’s earnings release in January 2025. The number of adjusted scripts grew to 1.62 billion, compared with 1.54 billion in 2023.