Earlier this year, Optum Rx announced it would shift to a cost-based model, which would boost reimbursements for brand-name drugs at community pharmacies.
Now, the pharmacy benefit management giant has revealed that it's officially expanded the model to reach 100% of the community and independent pharmacies in its network. The company has signed on three more pharmacy service administration organizations, or PSAOs, bringing the total number of participating pharmacies to 17,000.
Optum said earlier this year it expects to have the model rolled out in full by January 2028.
Mary Jo Jones, vice president for network contracting and industry relations at Optum Rx, told Fierce Healthcare that Optum began building its new model in response to utilization shifts in the pharmacy space.
The system has historically worked to encourage the use of generics, but Optum said there has been an uptick in the use of branded prescriptions that is driving up costs for pharmacies.
"To help the pharmacies adapt, the new reimbursement model is designed to better match these rising costs," Jones said. "This provides financial predictability through the new model, and it will allow these pharmacies to stock more medications and make it easier for people to get the prescriptions that they need."
Optum noted in the announcement that pharmaceutical companies launched new branded products in 2023 at prices that were 35% higher than in the prior year. List prices in the U.S. are often far higher than in other nations.
Brian Hose, CEO of Epic Pharmacy Network, called the new model a "meaningful step in the right direction" in the press release.
"Although this doesn’t solve all the reimbursement issues in the independent pharmacy community, together with EPN, Optum Rx has made an investment in brand reimbursements while preserving generic profitability," Hose said. "It is a meaningful step in the right direction, and we look forward to expanding our partnership with Optum Rx to support our network of pharmacies and their patients."
Jones told Fierce that the Optum team collaborated closely with PSAO partners as it rethought its approach to pharmacy reimbursement. That feedback was critical in shaping the direction of these efforts, she said.
"These discussions really helped shape our model and shaped our contracts that we are offering to them to make sure we're supporting their needs, supporting member access and costs and ultimately making sure that healthcare is affordable for everyone," Jones said.
She said discussions are still ongoing, too, as the team looks to continue to build on the new model and other efforts to support community and independent pharmacies.
Jones said there's been particular interest around GLP-1s and specialty drug products, both of which are major cost drivers.
"We've heard a lot from independent pharmacies, particularly about how can they operate to the top of their license," she said.