Series: The Truth About the Top Three PBMs

(OptumRx, owned by UnitedHealth Group) 

It’s been well reported that the top three PBMs control nearly 80% of all U.S. prescription drug claims. They were originally established to negotiate prescription drug savings for patients, employers and taxpayers – and yet, Americans continue to face higher out-of-pocket costs for the medicines they need.   

So, who are these PBMs and how can we separate fact from fiction?   

Let’s take a closer look at the Big Three corporate middlemen in the drug supply chain, and how their business practices shape what patients pay at the pharmacy. This overview breaks down who owns the PBMs, how they operate and how their business decisions influence drug pricing throughout the drug supply chain. Most importantly, these dynamics underscore the need for PBM reform and more transparency around vertical integration.  

Next up: OptumRx, owned by UnitedHealth Group. [insert any previous blogs here] 

UnitedHealth Group’s Ownership and Market Influence 

OptumRx is the pharmacy benefit manager arm of UnitedHealth Group, the largest health insurer in the country. As part of UnitedHealth’s broader health services and insurance platform, OptumRx handles a significant share of U.S. prescription drug claims while operating alongside the insurer and businesses. 

This vertical integration gives UnitedHealth Group deep reach into benefit design, drug pricing negotiations, coverage decisions and patient care management. Recent reporting shows that federal investigators are now examining how OptumRx runs its prescription management services and reimburses affiliated physicians as part of a wide-ranging Justice Department probe into UnitedHealth’s practices. 

Group Purchasing Organizations, or GPOs, add another level of complexity to the healthcare system. They serve as middlemen between drug manufacturers and vertically integrated insurers, PBMs and their affiliated pharmacies. According to a recent Hunterbrook report, Kent Rogers, who helped launch a GPO, Emisar, while at UnitedHealth’s Optum, stated that PBM-linked GPOs can earn “tens of millions, if not nearly $100 million, per employee.” 

Patient Impact 

OptumRx has been at the center of national debate over PBM influence on drug costs. In 2024, the Federal Trade Commission filed an administrative complaint against OptumRx and the other major PBMs, alleging anticompetitive rebate practices that inflated insulin list prices and limited access to lower-cost alternatives. The FTC said these kinds of rebate schemes shifted costs onto patients who rely on lifesaving medications like insulin. 

Critics also point to broader effects of PBM practices on community pharmacies generally. Data from independent advocacy groups show thousands of pharmacy closures in recent years, in part because large PBMs like OptumRx reimburse at rates that make it difficult for independent pharmacies to stay in business.  

Consequences for Employers, Pharmacies and Taxpayers 

The impact of OptumRx’s market power extends beyond individual patients. Employers and public health plans rely on PBMs to manage prescription benefits efficiently and transparently, yet many report ongoing challenges understanding where negotiated savings actually go. While PBMs often highlight rebate negotiations as a cost-saving tool, employers continue to question whether those dollars are fully passed through or retained within vertically integrated systems. 

Independent and community pharmacies face particularly acute pressure. Reimbursement rates set by large PBMs like OptumRx can fall below the cost of acquiring and dispensing medications, forcing pharmacies to absorb losses simply to serve patients. Over time, this dynamic contributes to pharmacy closures and reduced access to care, especially in rural and underserved communities where independent pharmacies are often the primary point of care.

Reform is Needed 

UnitedHealth Group’s ownership of OptumRx has made one company extraordinarily influential in the prescription drug supply chain. From pricing negotiations to pharmacy reimbursements, coverage decisions and rebate arrangements, the PBM exerts power at multiple points that can raise costs for patients, strain independent pharmacies and obscure how much consumers and employers really save. 

As policymakers, employers and consumers continue to scrutinize PBM practices, understanding how these powerful entities operate is essential to evaluating where reforms are needed and how the system can better serve the people who rely on it for their medications. Learn more about policy solutions here.