OptumRX Continues The Game
Another perfect example of PBM attempted overreach: changing a contract requirement in the middle of the contract term, creating hostile dispensing environment(s) for retail dispensing pharmacies, potentially conflicting already existing multiple state & federal laws, creating anticompetitive scenarios – with the only potential intent to hold pharmacies hostage for funds, with zero recourse outside of lawsuit…
OptumRX just announced a recent change to the existing contract for contracted pharmacies for 2025 data. This change states that pharmacies are required to maintain dispensing prescriptions to less than 25% for any therapeutic class. In other words, if a region has a very high instance of high blood pressure, diabetes, high cholesterol, headaches, or any specific condition or group of conditions requiring treatment for a specific drug class, your pharmacy dispensing those prescriptions is now non-compliant with the OptumRX contract and will be penalized for such non-compliance. This holds absolutely nothing for clinical value, specific outcomes or even a purpose of safety for patients.
Today, PBM’s are continuing to blatantly push an agenda, one that holds true harm for patients and communities, all for the purpose of lining the pockets of those already beyond a super-rich any of us can even dream about… So many cases of potential harm have already been surmised and published with numerous groups, but here are some perfect examples how your community may be effected…
Examples Illustrating Real-World Harm
These risks have been shown to already occur, and therefore are likely non-compliance scenarios with the new OptumRX contract change:
- A small pharmacy (most likely rural) experiencing an influx of respiratory prescriptions during influenza season or natural disasters could exceed the 25-percent limit precisely when its community relies on it most.
- A pharmacy specializing in diabetes, kidney-related, cancer, or heart-related care could routinely dispense more than 50 percent of a therapeutic class, placing it at immediate risk of denial despite its expertise and patient need.
- A pharmacy providing large volumes of vaccinations during peak immunization season could surpass the threshold solely because it is serving public-health needs.
- A pharmacy serving a long-term care population with specific wards for psychiatric or neurological conditions could be penalized for dispensing medically appropriate medications necessary for management of multiple mental health conditions.
These PBM’s must be shown they are no longer able to continually make rules that are designed solely for the purpose of lining their pockets at the expense of every other interested party. Legislators, regulators, and every interested party should put a stop to these thieves, putting them back in their place of simply streamlining a process of complex treatment paradigms and associated treatment formularies amongst multiple invested parties (pharmacies, employers, providers, and possibly even additional payers).
Sign the petition at the top of the page – start the process of taking control of your health and the safety of your community immediately! Then, share it to every person you know and have them do the same!