News

April 11, 2025, is the official deadline to submit data to PAI in order for it to be included within our RxDC reporting. Important updates for 2025 reporting of the 2024 data: CMS guidance was released in January, confirming no changes. We are not collecting and reporting third party carve-out vendor data. Please see below for more information. Official deadline to submit data to us is April 11, 2025.

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 November 2024 Pharmacy and Therapeutics Committee (P&T) meeting. Members negatively impacted by one of these changes will be sent a letter in February.

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.

These changes apply to all groups that have OptumRx as their PBM and use the Lowest Net Cost (LNC) Formulary. They do NOT apply to groups using any other formulary.

According to a new report from PricewaterhouseCoopers' (PwC) Health Research Institute, healthcare costs are expected to grow by 8% next year — which is the largest projected increase since 2012.1

Planned Administrators, Inc. (PAI) is partnering with Health at Scale to identify inappropriate healthcare claims before they are paid. Through the partnership, PAI will use Health at Scale’s breakthrough technology for real-time screening of claims

The changes in this bulletin apply to all groups that use OptumRx 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

We have recently updated our Humira/biosimilar coverage for members with PAI’s pharmacy benefit coverage with OptumRx that use the Lowest Net Cost (LNC) Formulary.