News

Recently, three pharmaceutical manufacturers announced significant pricing changes to their insulin products in response to regulatory and industry factors stemming from implementation of the American Rescue Plan Act of 2021, along with changes made to eliminate the Medicaid Rebate Cap starting January 1, 2024. While this change will result in a price decrease for these products to members, manufacturer rebates to the health plan will also decrease, or be eliminated. However, the pricing change will also result in a similar decrease in the cost of claims to the plan.

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

The PAI Marketing team entered four pieces to the 2023 MarCom awards and came out with two gold wins. MarCom Awards is an international creative competition that recognizes outstanding achievement by marketing and communication professionals. Entries

Seasonal Preventive Flu Vaccines Members with PAI 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 PAI pharmacy benefit coverage with OptumRx that use the Lowest Net Cost (LNC) Formulary will have pharmacy changes effective October 1, 2023.

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

The federal government confirmed May 11, 2023, as the end of the COVID-19 public health emergency (PHE). Our Pharmacy Benefit Manager (PBM) Optum Rx has been planning for this change and reviewing recent guidance from the government agencies on how

Earlier this month, the U.S. Department of Health and Human Services’ Office for Civil Rights (OCR) announces that the Notifications of Enforcement Discretion issued under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and

CMS has released updated RxDC Reporting Instructions for the 2022 Reference Year. These updated instructions will apply to the 2022 calendar year reporting, due June 1, 2023. According to the updated instructions document, the most significant