Optum Rx Increases Reimbursement for Independent Pharmacists

Optum Rx has increased reimbursement minimums on brand drugs for approximately independent pharmacies across the country. The company said this builds on an effort launched in March 2025 to align payment models more closely to the costs pharmacies may face.

In March, Optum Rx moved to a cost-based payment model for all 24,000 community pharmacies in its network. As of Sept. 1, 2025, Optum Rx added 2,300 independent pharmacies – those not affiliated with a pharmacy services administrative organization (PSAO), chain or other entity – to the program.

Anne Lawlor

“The legacy system used across the industry was designed to incentivize the use of generic drugs by reimbursing them at a higher percentage, while brands received lower reimbursement margins,” Anne Lawlor, senior vice president, network contracting and strategy at Optum Rx, told Formulary Watch. “By increasing brand reimbursement minimums for approximately 2,300 independent pharmacies nationwide, Optum Rx will help ensure that prescriptions filled by these pharmacies are reimbursed at a positive margin, resulting in more sustainable and predictable access.”

Lawlor said Optum Rx is making this move to support pharmacies’ long-term sustainability. “It means more predictable and sustainable reimbursement for pharmacies, which is expected to improve the overall experience for patients by improving access and reducing drug shortages,” she said.

By increasing brand reimbursement minimums, pharmacists will also have more financial flexibility and predictability.

These efforts, Optum Rx said, and commitments made earlier this year will increase transparency, support pharmacies and increase access for patients. Last year, Optum Rx eliminated all clawbacks and direct and indirect remuneration fees.

CMS had eliminated retroactive DIR fees in 2024 for PBMs, Medicare Advantage and pharmacies participating in Medicare Part D plans. Between 2010 and 2020, CMS reported that retroactive DIR fees increased by a staggering 107,400%.

Related: Optum Rx Eliminates Reauthorization on an Additional 60 Drugs

Additionally, Optum Rx has eliminated reauthorization on more than 140 drugs for chronic diseases, with a commitment to work with physicians and pharmacists to expand the list of eligible medications over time. Optum Rx has also made a commitment to pass through all drug rebate discounts to clients by Jan. 1, 2028.

These moves are coming at a time when PBMs are facing increased scrutiny of pharmacy reimbursement and efforts for transparency with employers, especially with regard to rebates. Employers have been calling for greater transparency and stronger partnerships with PBMs as they continue to face rising prescription drug costs and complicated benefit design.

Related: Swearing Off Rebates? Payers Say They Are Interested but Not Giving Them Up Just Yet

Understanding total costs is still challenging for payers, according to a report issued earlier this year from Pharmaceutical Strategies Group’s (PSG) 2025 Trends in Specialty Drugs. A third of respondents to the survey are actively working to implement rebate alternatives. But it’s hard to move away from rebates. Two-thirds of the respondents in the PSG survey said their plan has experienced an increase in the amount of rebates they have received.