Effective Every January 1 and July 1
Twice per year, OptumRx®, your pharmacy care services company, reviews its formulary – the list of covered drugs – and makes changes based on safety, cost, and effectiveness. These modifications may impact coverage of your current prescriptions. If a formulary change affects you, OptumRx will send you a letter to notify you and let you know the steps you need to take:
Formulary Exclusion: If OptumRx determines that a medication works the same as, or similar to, another prescription or over-the counter medication, it may exclude a particular drug. If the excluded drug is one you are taking, they will notify you. Talk with your doctor to discuss alternative options.
Step Therapy: Under step therapy, you must first try a Step 1 drug before the plan covers a Step 2 drug. If you are taking a Step 2 drug, OptumRx will notify you of the alternative medications you must try before they will cover the drug you are currently taking. If you previously tried a Step 1 drug and it didn’t work, or if your doctor wants you to continue taking the Step 2 drug due to medical necessity, your doctor must contact OptumRx to ask for a prior authorization.
Tier Change: If you are taking a prescription drug that will be moving to the most expensive copay or coinsurance tier, OptumRx will send you a list of alternative safe and effective options. Ask your doctor for a new prescription if one of these less-expensive options is right for you. Note that if your current prescription drug moves to a lower-cost tier, you won’t receive a letter, you’ll just pay the lower copay or coinsurance amount.
Prior Authorization: requires your doctor to provide additional information to OptumRx to determine coverage under your pharmacy benefit. If you are taking a prescription drug subject to prior authorization, you will receive a letter advising you that your doctor must contact OptumRx for a prior authorization. Contact your doctor to avoid uninterrupted coverage.
