Optum Rx, UnitedHealth Group’s pharmacy benefit manager, said it will roll out a fee-based structure to customers in the coming years.
A May 11 news release from Optum said Optum Rx’s agreements have traditionally been linked to drug prices or prescription volume. The transition to flat group-purchasing fees will be finalized by the end of 2027. The company will also report fees to improve transparency, and an independent third party will validate the group purchasing organization’s bona fide service fees, Optum Rx CEO Jon Mahrt told Becker’s.
“We’re delinking GPO fees from drug prices,” he said. “Gone are the days of ever questioning whether PBMs make more money as drug prices increase or you dispense more drugs.”
Under the transformation, Optum Rx will adopt a pricing structure in which plan sponsors pay monthly, defined fees per member, as well, eliminating spread pricing.
The initiative builds on previous transparency commitments, like passing through 100% of rebates by 2028.
Cigna’s health services division has also acknowledged the need for a shift with pharmacy benefits. Evernorth recently introduced a rebate-free model for Express Scripts. Cigna leadership cautioned the pivot would “incur short-term investment and transition costs” during an earnings call.
“We have a lot of work to do as a leadership team. We’re out negotiating with manufacturers. We’re reworking client agreements,” Mr. Mahrt said. “There’s a lot of lift.”
However, he still anticipates margins ranging from 3% to 5%.
“This is really resonating with new clients,” he said.
In recent years, PBMs have faced heightened Congressional scrutiny, prompting reforms. Some states, such as California, have cracked down on spread pricing. Mr. Mahrt said the regulatory landscape influenced the move’s timing.
“I spent time with well more than 100 policymakers last year listening to their voices in the same way as clients,” he said. “Everybody wants it to change. We get to define that change.”
Optum Rx is also launching digital resources to alert patients about prescription pricing, pharmacies and delivery options. Mr. Mahrt said Optum Rx is scaling access to drugs offered under acquisition cost-plus pricing, as well.
Optum Rx expects to share more updates about prior authorization and consumer experience efforts in the summer.
“We’re just getting started,” he said.
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