Optum Rx has officially announced the modernization of its pharmacy payment models.
According to certain reports, the company will align payment models, effective immediately and with full implementation planned by January 2028, more closely to the costs that pharmacies may have to put up with because of manufacturer pricing actions.
More on that would reveal how such a change should positively impact Optum Rx non-affiliated network pharmacies, including the more than 24,000 independent, community pharmacies. Not just that, these cost-based payment models will also provide more consistently affordable experiences for end consumers.
By doing so, the company will also look to address a legacy industry-wide model, originally designed to help promote the use of affordable generics. You see, this move will tread up a long distance to provide pharmacies with better financial means to stock more medicines, alleviating drug shortages, improving access to medications, and at the same time, delivering a better experience for consumers.
“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., chief executive officer 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.”
Beyond that, Optum Rx will also try and transition client arrangements, such as employer and health plan customers, to ensure transparency and greater alignment to drug costs.
The move in question follows up on the company’s recent commitment to pass through 100% of drug rebate discounts negotiated with pharmaceutical manufacturers to clients by January 1, 2028. Both these efforts, though, build upon on Optum Rx’s assortment of historical efforts towards ensuring pharmacies are paid fairly.
Talk about the given efforts on a slightly deeper level, they include reimbursing pharmacists for connecting their underserved patients to services that address basic needs, including food, nutrition, transportation, housing and baby supplies. Here, the key focus areas are understood to be maternal wellness and meeting health care needs across urban and rural communities that still have a scarcity of pharmacies.
Next up, there was an initiative focused on supporting independent pharmacists by paying them for services like counseling and medication management aimed at improving patient outcomes. Optum Rx has also made an effort to scale up pharmacy digital capabilities to easily access claims and payment data, ease administrative burdens, and manage revenue.
Among other things, we ought to mention how the company has effectively removed retroactive recoupment (also known as clawbacks) for pharmacies, while simultaneously offering predictive analytics and other tools to further reduce administrative burden and allow more time to focus on patient care.
We must also mention that Epic Pharmacy Network (EPN), a Pharmacy Services Administrative Organization representing over 1,000 independent pharmacies across US, has inked a partnership with Optum Rx to conjure up a cost-based reimbursement model.
Founded back in 1989, Optum Rx’s rise up the ranks stems from delivering intelligent, integrated solutions that help modernize the health system and improve overall population health. The company’s excellence in what it does can also be gauged once you consider it serves, at the moment, more than 210,000 people across the globe.
“Our pharmacists are critical partners in care and often the most consistent health care provider for the patients and communities they serve,” said Bretta Grinsteinner of EPN. “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 to address reimbursement issues that plague pharmacies nationwide.”
