The facts about pharmacy benefit managers

Fact: Only drug manufacturers have the power to set and raise drug prices. PBMs are the only counterweight working to lower medication costs by negotiating on behalf of plan sponsors to keep costs as low as possible for clients and consumers.

In fact, in January 2025, Optum Rx announced that 100% of rebates will be passed through to clients by 2028. Prior to January 2025, 98% of rebates were passed through to clients.

Fact: PBM clients, including health plans, large employers and government payers, make their own formulary choices based on their preferred benefits design. PBM-developed formularies are grounded in clinical rigor and guided by independent Pharmacy and Therapeutics (P&T) Committees.

Formularies designed by Optum Rx are guided by an independent P&T committee of 12 practicing physicians and pharmacists who do not work for UnitedHealth Group. As of January 1, 2026, the committee also includes a patient representative. This committee evaluates medications based on clinical efficacy and safety.

Clients retain final authority over which drugs are covered based on what works best for their members.

Fact: Optum Rx has set the industry standard as a comprehensive, transparent PBM by making benefits simple and more affordable for everyone we serve. We offer full transparency into:

• Audit rights
• Drug evaluation
• Formulary placement
• Pricing

Providers can access patient-specific cost and coverage information. Members receive savings alerts and guidance on the lowest price.

Fact: Community and independent pharmacies are on the front lines of health care and serve a critical role in connecting patients to care and resources. That's why PBMs include community and independent pharmacies in their pharmacy networks with reimbursement rates that are often higher than retail chain pharmacies.

For our part, this year Optum Rx announced modernized pharmacy payment models and increased reimbursement minimums on brand drugs to support the long-term sustainability of community and independent pharmacies.

Fact: PBMs ensure members have access to the medication they need, when they need it, at the lowest cost. PBMs aim to provide clients with many options for pharmacy networks, and their members are able to choose what works best for them.

Optum pharmacies serve patients across a wide spectrum of healthcare coverage and life settings, in both rural and urban areas, including people who are facing housing insecurity, homebound, hospitalized or living in nursing homes.

Many patients are also managing complex or rare conditions that require specialized and personalized clinical expertise, proactive care management and access to high-cost, limited-distribution medications.

Fact: GPOs help lower drug costs through:

• Consolidated purchasing power
• Access to a wider range of products
• Better ability to negotiate with drug manufacturers.

As a result, GPOs are able to drive savings for clients and members.