News

The changes in this update apply to all groups that use OptumRx The majority of these changes include decisions that occurred as a result of our August 2024 Pharmacy and Therapeutics Committee (P&T) meeting. Members negatively impacted by one of these changes will be sent a letter in November.

Beginning Jan. 1, 2025, Humira (brand) will be removed from the Lowest Net Cost formulary. Adalimumab biosimilars will instead be the preferred products for this formulary.

The vaccines and immunizations in this update apply to all groups that use OptumRx, as summarized in the ‘Seasonal Vaccine Coverage’ and ‘Non-seasonal Coverage’ sections, align with the recommended vaccines included on the ACA HCR list of preventive medications. This list undergoes periodic review and may change based on guideline updates.

Similar to the changes recently made to Zepbound, it has been brought to our attention that members on plans that do NOT include weight loss medications were unable to fully utilize manufacturer copay assistance cards for the drug Wegovy. This was due to discounts from the “Enhanced Savings Program” (ESP)

We have recently updated our Humira/biosimilar coverage for members with BSA's pharmacy benefit coverage with OptumRx that use the Lowest Net Cost (LNC) Formulary. Make sure to check your benefit plan for eligibility. Strategies through the remainder

The changes in this bulletin apply to all groups that use OptumRx Lowest Net Cost (LNC) Formulary.

The changes in this bulletin apply to all groups that use OptumRx Lowest Net Cost (LNC) Formulary. These changes include decisions that occurred as a result of our September 2023 Pharmacy and Therapeutics Committee (P&T) meeting. Members negatively impacted by one of these changes will be sent a letter in November.

Seasonal Preventive Flu Vaccines Members with BSA pharmacy benefit coverage with OptumRx can get flu vaccines covered under their pharmacy benefit at any in-network pharmacy. Flu vaccines administered by network pharmacies are subject to an administration fee that will be the group’s responsibility. Members are responsible for the full cost of the vaccine administered in out-of-network pharmacies.

To support appropriate utilization management, we continually review relevant clinical guidelines and reassess our requirements. Utilization management criteria for Freestyle and Dexcom CGMs will be updated for some of our formularies effective September 11, 2023.

Members with Blue Solutions pharmacy benefit coverage with OptumRx, we will be adding Hadlima and Adalimumab-adaz—biosimilar options for Humira