UnitedHealth To Overhaul Payment Model To Support Independent Pharmacies

On Thursday, UnitedHealth Group Inc‘s UNH Optum Rx will align payment models more closely to the costs pharmacies may face due to manufacturer pricing actions.

The company plans a full implementation by January 2028.

In February, President Donald Trump signed an executive order to strengthen price transparency regulations in the industry.

The order directs federal agencies, including the Departments of Treasury, Labor, and Health and Human Services, to enforce and expand a 2019 rule requiring hospitals and insurers to publicly disclose the actual costs of medical services.

This change will positively impact Optum Rx’s non-affiliated network pharmacies, including the more than 24,000 independent community pharmacies.

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“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, 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 will similarly transition client arrangements—such as employer and health plan customers—to ensure transparency and greater alignment with drug costs.

Optum Rx has been working to ensure pharmacies are paid fairly and offering solutions to improve operational efficiency and reduce administrative burden. Some of these efforts include:

Reimbursing 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 with few pharmacies.
Supporting independent pharmacists by paying them for services such as counseling and medication management.
Enhancing pharmacy digital capabilities to easily access claims and payment data, ease administrative burdens, and manage revenue.
Removing retroactive recoupment (clawbacks) for pharmacies.
Offering predictive analytics and other tools.

On Wednesday, Optum Rx announced that it would eliminate up to 25% of reauthorizations, equal to more than 10% of overall pharmacy prior authorizations, to make prescription drugs more affordable and the pharmacy experience simpler.

The initiative focuses first on approximately 80 drugs, and Optum Rx will work with physicians and pharmacists to expand the list over time.

Optum Rx said that some reauthorizations are necessary for drugs with safety concerns, which need ongoing monitoring for dose adjustments, require additional tests, or may have alternative therapy considerations.

For example, new drugs developed for Alzheimer’s disease carry risks for the brain, and long-term effectiveness is not clear.

For these treatments, ongoing review is important for patients, payers and physicians. In contrast, once a genetic condition like cystic fibrosis is confirmed through testing, there is minimal additional value in reauthorizing an effective, lifelong treatment.

Price Action: UNH stock is up 0.36% at $505 during the premarket session at the last check Thursday.

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