Optum Rx, the pharmacy benefit manager (PBM) of UnitedHealth Group, is rolling out a major structural reform. The company plans to fully delink its fees from drug prices. This shift marks one of the most significant pricing changes in PBM history.
What Is Changing at Optum Rx?
For years, Optum Rx tied its compensation agreements to drug prices or prescription volume. That approach is now ending. On May 11, the company officially announced a move to a flat fee-based structure. The transition will complete by the end of 2027.
Optum Rx CEO Jon Mahrt spoke directly about the change. “We’re delinking GPO fees from drug prices,” he said. “Gone are the days of ever questioning whether PBMs make more money as drug prices increase or you dispense more drugs.”
This statement captures the core intent behind the reform: eliminating financial incentives that previously rewarded higher drug prices.
How the New Fee Structure Works
Moving Away from Volume-Based Agreements
Previously, Optum Rx earned more when drug costs rose or when prescription volumes increased. This model created a conflict of interest. Critics argued it gave PBMs little reason to push drug prices down. The new structure removes that conflict entirely.
Instead, Optum Rx will charge fixed fees. These fees no longer depend on what drugs cost or how many prescriptions are filled. As a result, clients gain greater pricing predictability.
Flat Per-Member Monthly Fees Explained
Under the new model, plan sponsors will pay defined monthly fees per member. This approach eliminates spread pricing, which has drawn heavy criticism from employers and regulators. Spread pricing allows PBMs to charge plans more than they reimburse pharmacies, pocketing the difference. Optum Rx is ending that practice.
Moreover, the company will report all fees openly. Transparency, therefore, becomes a built-in feature of the new model, not an afterthought.
Third-Party Validation of GPO Fees
An independent third party will validate the group purchasing organization’s bona fide service fees. This added layer of oversight strengthens credibility. Clients can trust the numbers they receive. Additionally, this validation process directly addresses longstanding concerns about PBM opacity.
Why This Move Matters for the PBM Industry
Congressional Pressure and Regulatory Influence
PBMs have faced intense scrutiny from U.S. Congress in recent years. Bipartisan pressure has pushed the industry toward greater accountability. Several states have already acted independently. California, for instance, has cracked down on spread pricing practices.
Mahrt acknowledged that regulatory momentum influenced the timing of this announcement. “I spent time with well more than 100 policymakers last year listening to their voices,” he said. “Everybody wants it to change. We get to define that change.”
Furthermore, this reform builds on Optum Rx’s earlier commitment to pass through 100% of rebates by 2028. The company is clearly accelerating its transparency agenda.
How Competitors Are Responding
Optum Rx is not alone in rethinking PBM models. Cigna’s health services division, Evernorth, recently introduced a rebate-free model for Express Scripts. However, Cigna leadership cautioned that this pivot would involve short-term investment and transition costs.
Consequently, both major PBMs are moving in a similar direction. The industry-wide shift toward transparency reflects growing pressure from clients, regulators, and the public alike.
What Comes Next for Optum Rx
Mahrt estimates that margins under the new model will range from 3% to 5%. He also noted strong early interest from new clients. “This is really resonating with new clients,” he said.
Additionally, Optum Rx is launching digital tools to help patients understand prescription pricing, find pharmacies, and explore delivery options. The company is also expanding access to drugs under acquisition cost-plus pricing.
Further updates on prior authorization and consumer experience improvements are expected this summer. “We’re just getting started,” Mahrt said.
The transition ahead is substantial. Mahrt described ongoing work across negotiations with manufacturers and restructuring of client agreements. “There’s a lot of lift,” he acknowledged. Nevertheless, the direction is clear: Optum Rx is building a simpler, more transparent PBM for the future.
