OptumRx Rolls Out Transparent Reimbursement
OptumRx says it is rolling out a new cost-based reimbursement model for pharmacies. It says it expects the change to be a positive one for the more than 24,000 independent and community pharmacies as well as members. Optum said it will begin to roll out the updated models now and intends to have a full implementation in place by January 2028.
The model will reimburse pharmacies more for dispensing brand-name medicines to address longstanding complaints that expensive prescriptions are losing money for drugstores. The model recognizes that with the penetration of generics, some work must be done to deal with the brand reimbursement problem. This will help stocking of brand drugs.
Pharmacists are skeptical and feel this is an effort to forestall passage of pharmacy benefits manager (PBM) reform.
Additional articles: https://www.modernhealthcare.com/insurance/unitedhealth-optumrx-brand-name-drugs and https://insidehealthpolicy.com/inside-drug-pricing-daily-news/new-optum-rx-pharmacy-pay-model-met-skepticism
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#drugpricing #pbms
https://www.fiercehealthcare.com/payers/optum-rx-overhaul-pharmacy-reimbursement-models
C-SNPs Growth Phenomenal
This Modern Healthcare article does a good job of discussing the growth in Medicare Advantage Chronic Care Special Needs Plans (C-SNPs). While Dual Eligible SNPs (D-SNPs) continue to dominate the specialized MA market, C-SNPs, centered on those with chronic illness, are seeing major investments as well. C-SNPs rose from 662K in 2024 to1.108M now.
(Article may require a subscription.)
#snps #medicareadvantage
https://www.modernhealthcare.com/insurance/c-snp-market-unitedhealth-scan-2025
WSJ Reveals More Potential 340B Abuse
The Wall Street Journal (WSJ) says drug middlemen are using the 340B program to move employee spending to hospital pharmacies for savings. Some question whether significant savings are accruing to the employer and employee or largely to hospitals’ bottom line. At any rate, it would appear the scheme does not meet the spirit of the 340B discount drug pricing program’s intent to serve the poor.
The 340B hospitals purchased $66 billion in drugs with a 55% discount. The program needs radical reform.
(Article may require a subscription.)
#drugpricing #340b #hospitals #branddrugmakers
New Report Says 1M Could Lose Exchange Coverage Under New Rule
A new Trump administration rule proposing to shorten the annual enrollment period for Exchange coverage by one month could means more than 1 million Americans at risk of losing coverage. The rule would contract the open enrollment period for 2026 to Nov. 1 through Dec. 15.
#aca #obamacare #exchanges
— Marc S. Ryan
