Optum Rx to transition to flat service fee model

By the end of 2027, Optum Rx will fully transition to a flat fee-based structure. Under the new approach, Optum Rx clients will be offered a pricing structure with monthly defined fees per member that are independent of manufacturers’ list prices or prescription volume, eliminating spread pricing and similar practices. Every client will have transparency into Optum Rx fees, including those associated with its group purchasing organization.

In a news release, company executives said this effort to switch to a flat fee structure builds on previous efforts, such as committing to passing through 100% of manufacturer drug rebate discounts to clients by Jan. 1, 2028. The model is designed to align incentives with patients and plan sponsors.

Optum Rx is also launching digital tools that help consumers compare pricing and know the cost of their medication before they go to the pharmacy. “By combining economic transparency for clients with digital tools that help patients shop for affordable options, we’re delivering a pharmacy system that is simple, easier to navigate and offers greater value,” Jon Mahrt, CEO of Optum Rx and chief growth officer of Optum, a part of UnitedHealth Group, said in a news release.

The digital tools for consumers include Shop MyScript, which notifies eligible Optum Rx patients immediately after a prescription is written, and Price Wise, which displays a full cost breakdown, including the drug price and a clearly defined service fee.

Related: 4 takeaways from UnitedHealth Group’s first quarter earnings call

UnitedHealth Group executives said in an April 21, 2026, investor call that they remain focused on transparency, pointing to a 15-part Transparency Guarantee. This includes the company’s PriceEdge affordability tool, which now serves 14 million members and compares direct-to-consumer cash prices for generic drugs against insurance pricing. Executives said their combined affordability programs — including Specialty Savings IQ and critical drug initiatives — would deliver more than $1.5 billion in savings to patients this year. More than 80% of claims through the Optum Rx flow through a network where independent pharmacies are reimbursed at cost-based rates.

Additionally, Optum Rx has eliminated 33% of drug reauthorizations, representing 11% of pharmacy prior authorizations. Optum Rx’s PreCheck prior authorization capability now reduces prescription approval time from over eight hours to under 30 seconds, delivering a 68% reduction in denials due to missing information and an 88% reduction in appeals, Patrick Conway, CEO of Optum, said in a recent earnings call.

Optum Rx, Conway said, started the year by onboarding more than 800 new clients for PreCheck while reducing contact call center volumes 25% through enhanced digital and AI-enabled self-service, with member satisfaction over 95%. Currently, the company is scaling up the program with the Cleveland Clinic with a goal of more than 20 health systems using PreCheck this year.

Optum Rx’s move to a rebate-free model follows efforts by other PBMs to adjust their business practices after intense scrutiny of rebates. Evernorth, for example, launched Evernorth Signature Pharmacy Benefits Services, which will become the standard model for all Evernorth pharmacy benefit clients in 2028. This new program ends the use of rebates and lowers the cost of brand-name medications by 30%, a spokesperson for the company told Managed Healthcare Executive. Evernorth plans to integrate this model with new direct-to-patient programs when they become available.

Evernorth, which is a part of Cigna, first announced the new program in October 2025, and company executives said they were targeting at least 50% of Evernorth pharmacy benefit services members enrolled in Signature by 2028. Fully insured Cigna Healthcare customers will automatically transition to the new model as part of normal renewals.

As part of Signature, patients will be guaranteed the lowest out-of-pocket cost at the point of sale, whether through negotiated pricing, copays, or cash-pay alternatives, with any cash-pay amounts counting toward the member’s deductible.

“Affordability of prescription drugs continues to be one of the top challenges facing both patients and therefore the entire pharmacy benefits industry,” Brian Evanko said during a recent earnings call. “Nearly all key stakeholders, whether they’re employers, whether they’re brokers, or whether they’re drug manufacturers themselves, acknowledge that the status quo is unsustainable.” Evanko will become CEO of The Cigna Group after the current CEO, David M. Cordani, retires on July 1, 2026.