UnitedHealth’s PBM, Optum Rx, launches a more 'transparent' drug pricing model
Pharmacy benefit manager Optum Rx plans to launch Clear Trend Guarantee in 2025 to allow employers and health insurers to more easily manage their drug spending, while creating more predictability for patients around costs.
While major pharmacy benefit managers are facing intense scrutiny over drug pricing, UnitedHealth Group on Monday announced that its PBM, Optum Rx, will offer a new value-based pricing model next year: Optum Rx Clear Trend Guarantee will feature shared savings to promote efficient care while leveraging outcome-driven, member- or population-level, disease-specific data to identify more effective care pathways for members.
The announcement is part of a wave of changes from insurers to offer more transparency in drug pricing, as CVS Health introduced CostVantage, which sets costs based on the drug cost, set markup and a fee for pharmacy services, in 2023.
“It is more important now than ever before to be an innovator in health care and to drive affordability and value for plan sponsors and members,” Optum Rx CEO Patrick Conway said. “We are not stopping with Clear Trend Guarantee and will continue to deliver clear information, transparent and lowest net cost, choice and a simplified pharmacy benefit for everyone.” This new pricing model builds upon the Cost Made Clear payment solutions announced last year. Clear Trend Guarantee will offer drug benefit plan sponsors greater pharmacy spend predictability to help manage total lowest net cost, the company said.
The announcement noted that U.S. spending on drugs continues to rise, currently topping $711 billion and expected to reach $1 trillion by 2028. Optum Rx said plan sponsors save 27% using its in-network rates, reducing costs by about $43 billion in aggregate each year.
Currently, out-of-pocket drug prices are decided by a complex system that includes insurers, drugmakers, pharmacies and pharmacy benefit managers, resulting in ambiguity around markups to the original cost of the drug.
“As stakeholders in health care call for more transparency and value to combat rising drug prices set by drug manufacturers, the OptumRx PBM continues to expand choice and tailor how pharmacy benefits can meet the demands and budgets for benefit plan sponsors and people they represent,” the company said.
Cost Made Clear solutions, which currently are available to plan sponsors, include pass-through models that offer cost-plus pricing with lower ingredient costs. Clear Trend Guarantee is an alternative, guarantee-based pricing model that combines retail, home delivery, specialty drug and rebate components into one per-member guarantee.
“Compared to other models in the market that separate the guarantees, Clear Trend Guarantee ensures plan sponsors have a clear path to a bottom-line pharmacy benefits payment to support effective management of drug trend and spending,” the company said. “This will ultimately deliver value to individuals and families who want predictability in their premiums and drug costs.”
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Beginning Jan. 1, 2025, Optum Rx will offer Clear Trend Guarantee to drug benefit plan sponsors alongside a full suite of Cost Made Clear payment solutions and the traditional and pass-through models currently available.