Optum Rx Replaces Traditional PBM Model with Flat Fee-Based Structure

Optum Rx announced on May 12, 2026 that it will replace the traditional pharmacy benefit manager model with a flat fee-based structure, with group purchasing converting to flat service fees by the end of 2027. The Consolidated Appropriations Act of 2026 mandates rebate pass-through and delinks PBM compensation from drug prices. Optum Rx serves 61 million people and will pass through 100% of manufacturer drug rebate discounts to clients by January 1, 2028.

Flat fee-based PBM model

• ▪Optum Rx's new pricing structure offers monthly, clearly defined fees per member that are independent of manufacturers' list prices or prescription volume.
• ▪Optum Rx's new model eliminates spread pricing and similar practices.
• ▪Every Optum Rx client will have transparency into Optum Rx fees, including those associated with Optum Rx's group purchasing organization.
• ▪Optum Rx announced on May 12, 2026 that Optum Rx is replacing the traditional pharmacy benefit manager model with a transparent, fee-based structure.
• ▪Optum Rx will provide clear disclosure of payments received from pharmaceutical manufacturers to every client.
• ▪Optum Rx's group purchasing will fully transition to flat service fees by the end of 2027.

Patient digital pricing tools

• ▪Optum Rx's Price Wise tool displays the full cost breakdown including the drug price and a defined service fee, offering an all-in price through a partner pharmacy.
• ▪Optum Rx's Shop MyScript tool gives Optum Rx patients pricing, pharmacy options and delivery choices before the prescription is filled.

Recent Optum Rx initiatives

• ▪In January 2025, Optum Rx committed to passing through 100% of manufacturer drug rebate discounts to clients by January 1, 2028.
• ▪Optum Rx serves clients and nearly 61 million people with a nationwide network of more than 67,000 community pharmacies and home delivery pharmacies.
• ▪In March 2025, Optum Rx introduced pharmacy payment terms designed to reflect the actual costs pharmacies incur to deliver care through a partnership with Pharmacy Services Administration Organizations.
• ▪In September 2025, Optum Rx increased brand-name drug reimbursement for 2,300 community and independent pharmacies not affiliated with a PSAO, chain or other entity.
• ▪Since the beginning of 2025, Optum Rx eliminated 33% of drug reauthorizations, representing 11% of pharmacy prior authorizations, for a list of nearly 270 chronic condition medications.
• ▪One hundred percent of community and independent pharmacies in the Optum Rx network transitioned to cost-based payment arrangements in March 2025.

Congressional PBM reforms

• ▪The Consolidated Appropriations Act of 2026 includes provisions to delink PBM compensation in Medicare Part D prescription drug plans from the price of a drug or rebate arrangements.
• ▪The Consolidated Appropriations Act of 2026 requires PBM compensation to reflect fair-market value for services.
• ▪The Consolidated Appropriations Act of 2026 mandates 100% pass-through of manufacturer rebates to health plans.
• ▪The Consolidated Appropriations Act of 2026 increases oversight of PBM services for Part D plans and employer health plans through transparency and data reporting requirements.

Trump administration transparency rule

• ▪The Trump administration issued a proposed rule to require greater transparency from PBMs regarding their compensation in service contracts and arrangements with self-insured group health plans.
• ▪In April 2025, the Trump administration issued an Executive Order directing the Assistant to the President for Domestic Policy to re-evaluate the role of middlemen to promote a more competitive, efficient, transparent, and resilient pharmaceutical value chain.

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