Optum Rx to Offer Guarantee-Based Pricing Model

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The new program will launch in January 2025 and provide plan sponsors greater predictability of pharmacy spend.

Beginning Jan. 1, 2025, Optum Rx will offer a new value-based model for shared savings. The new program, Clear Trend Guarantee, offers a new benefits pricing solution that combines guarantees into a single per member cost. Company officials said in a news release that this provides plan sponsors greater predictability of pharmacy spend to help manage total lowest net cost.

The new program is an alternative model that combines retail, home delivery, specialty drug and rebate components into one per member guarantee. Optum Rx officials said this helps ensure plan sponsors have a clear path to a “bottom line” pharmacy benefits payment and adds predictability to costs.

The program applies discounts and rebates into a single net cost trend guarantee. It leverages outcome-driven, member or population level, disease-specific data to identify more effective care pathways for members

Clear Trend Guarantee can allow for pass through pricing and does allow for pass through rebates in the single guarantee. The program will use Optum Rx’s standard formularies and savings for Clear Trend Guarantee are generated through formulary changes and clinical program adoption, a spokesperson said.

PBMs continue to be under scrutiny for what many say are their lack of transparency about drug costs and payments to pharmacies. In December 2023, the House of Representatives passed legislation, called The Lower Costs, More Transparency Act, that would require transparency around PBMs, drug spending, formulary placement, and rebate information.

Just last week, protestors, including pharmacy groups, demonstrated outside Express Scripts’ offices because, according to an article in USA Today, of frustration about a lack of movement on the legislative front.

Related: Express Scripts Launches New Cost Plus Drug Model

In the meantime, PBMs are trying to address some of the criticisms about a lack of transparency. The three largest PBMs have all offered alternative programs. For example, last year, Optum Rx began offering two pricing options that aimed to bring players options for transparency and choice. One program, Cost Clarity, bases costs on independent costs baselines, such as the National Average Drug Acquisition Cost (NADAC) and wholesale costs. The other, Cost Advantage, uses a pass-through model using average ingredient costs and reflecting real-time network price improvements.

Optum Rx also began a program in January 2024 to reimburse pharmacists for some of the time they spend assisting patients. This program is connecting underserved patients in areas where there are pharmacy “deserts.”

Additionally, Express Scripts last year announced several new pricing options. New this year is a program for plans and employers that offers a more simple pricing structure. Called the Express Scripts ClearNetwork, this option uses the lowest benchmark – Predictive Acquisition Cost, National Average Drug Acquisition Cost, or Wholesale Acquisition Cost – to estimate the acquisition cost for an individual drug. A flat pharmacy fee and a second fee of 15% is added. Last year, Express Scripts launched ClearCareRx, where clients pay what Express Scripts pays pharmacies and also receive 100% of rebates negotiated with pharmaceutical companies.

CVS Caremark announced in December 2023 two programs that will launch in 2025. CVS CostVantage will use a transparent formula built on the cost of the drug, a set markup, and a fee that reflects the care and value of pharmacy services. TrueCost offers client pricing reflecting the net cost of prescription drugs, with visibility into administrative fees.

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