Optum Rx says it’s looking to ‘correct imbalances’ 

EDEN PRAIRIE, Minn. – Optum Rx will align payment models more closely to the costs pharmacies may face due to manufacturing pricing actions effective immediately and with full implementation by January 2028. 

The company says the change will positively impact its non-affiliated network pharmacies, including the more than 24,000 independent, community pharmacies it serves.  

“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., CEO 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.” 

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

As part of the model, Optum Rx will: 

• Reimburse 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. 
• Support independent pharmacists by paying them for services such as counseling and medication management aimed at improving patient outcomes. 
• Enhance pharmacy digital capabilities to easily access claims and payment data, ease administrative burdens and manage revenue. 
• Remove retroactive recoupment (“clawbacks”) for pharmacies. 
• Offer predictive analytics and other tools to further reduce administrative burden and allow more time to focus on patient care. 

The National Community Pharmacists Association (NCPA) says it would like to see more details about the plan. 

“We have seen announcements like this in the past by PBMs that claim they want to work with independent pharmacies,” it stated. “Based on the results to date, some were obviously intended as political cover or public relations. 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. 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.”