Optum Rx is shifting its payment models to better meet the needs of pharmacies and consumers, the pharmacy benefit manager announced Thursday.
The company said it will shift to a cost-based model, which will better align with "the costs pharmacies may face due to manufacturer pricing actions." The PBM expects the change to be a positive one for the more than 24,000 independent and community pharmacies it works with, along with its members.
Optum said it will begin to roll out the updated models now and intends to have a full implementation in place by January 2028.
“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,” Optum Rx CEO Patrick Conway, M.D., said in a press release.
“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," Conway added.
Existing payment approaches were designed initially to encourage the use of generics, which have now been widely adopted, Optum Rx said. Instead, high-cost branded therapies are coming to market, which can stretch independent pharmacies thin. Adjusting payment models to center on drug costs should make it easier for these pharmacies to stock medications, mitigating shortages and improving access.
For example, Optum said that Epic Pharmacy Network, a pharmacy services administrative organization that includes more than 1,000 independent pharmacies across the country, has partnered with Optum to pursue the cost-based model.
Bretta Grinsteinner, vice president of network development for EPN, said the change 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 to address reimbursement issues that plague pharmacies nationwide," she said.
In tandem, Optum said it will transition its client agreements, such as those for employers and health plans, to enhance transparency and better reflect pharmaceutical costs. It has set a similar timeline for these changes, which are already underway and expected to be completed by Jan. 1.
The payment model changes follow just one day after Optum Rx announced that it would ease reauthorization requirements for 80 drugs. The PBM said these changes will reduce its overall prior authorization requirements by about 10%.
The PBM industry has been under pressure from lawmakers and regulators over the role it plays in rising drug costs. While significant reform has not yet made it into law, changes have garnered bipartisan support.