Optum Rx is being sued after an essential asthma medication was removed from a patient's insurance formulary, leading to a sharp price hike that contributed to a preventable death. The company defended its actions by citing federal limitations and pointing to alternative options with minimal copays, while critics argue that these practices reflect a profit-driven approach that neglects patient welfare.

The article details how UnitedHealth Group leverages its PBM, Optum Rx, to influence drug pricing, rebates, and market access. This centralization of power contributes to problematic pricing strategies and market consolidation, fueling public frustration and regulatory scrutiny.

Optum Rx announced a new payment model aimed at correcting financial imbalances in pharmacy reimbursements. The change includes eliminating clawbacks, providing reimbursement for additional patient care services, and enhancing digital capabilities for better claim and payment management, all in collaboration with Epic Pharmacy Network, Inc. This model is designed to support over 24,000 independent and community pharmacies.

Optum Rx announced a shift to a cost-based pharmacy reimbursement model aimed at providing more reliable revenue for pharmacies, especially independent ones, in response to longstanding criticisms of the traditional, opaque payment system. The move is intended to rebalance financial pressures amidst widespread pharmacy closures and market instability.

Optum Rx announced a major initiative to modernize its pharmacy payment models, transitioning client arrangements to cost-based, transparent designs and ensuring independent pharmacies receive fair reimbursement with full implementation set by January 2028. The initiative also includes passing through 100% of drug rebate discounts, aiming to alleviate financial pressures on community pharmacies.

OptumRx agreed to pay $20 million to resolve allegations of improperly filling opioid prescriptions in violation of the Controlled Substances Act. The settlement follows an investigation by the DEA into practices that involved filling risky 'trinity' combinations of opioids, benzodiazepines, and muscle relaxants, raising serious concerns about the company's ethical standards and patient safety.

Optum Rx, through its External Affairs team, has actively engaged in influencing legislation and regulatory processes by meeting with over 150 state and federal policymakers. The company advocates against mandatory reforms in pharmacy benefit management that could alter pricing and reimbursement practices, reflecting efforts to preserve an industry-friendly regulatory framework.

OptumRx won a ruling that compels over 500 independent pharmacies to resolve their rebate claims through arbitration. The decision, handed down by the Florida Second District Court of Appeals on December 27, 2023, reinforces allegations by the pharmacies that the company engaged in practices such as underpaying for drugs, clawing back payments, and misbranding drugs as 'name brand' to reduce payouts.

Optum Rx’s regulatory updates page indicates that the company closely monitors and acts to influence legislation that could adversely impact pharmacy benefits for its clients. This activity suggests efforts to shape regulatory environments in favor of its business interests.

The California Court of Appeals upheld a lower court ruling that declared the forced arbitration clause in OptumRx’s pharmacy network contract unconscionable. This decision was applauded by independent pharmacies and advocates such as Pharmacists United for Truth and Transparency, highlighting the company's use of opaque and draconian contract terms that shift high arbitration costs onto pharmacies.

A March 1, 2023 letter from the US House Committee on Oversight and Accountability details investigations into OptumRx’s practices, including allegations of overcharging, self-benefiting pricing tactics, and market domination that are impacting patient care and transparency in the pharmaceutical market.