HEALTH BENEFITS UPDATE
Adjusting to the state’s new
pharmacy benefit manager
As of Jan. 1, 2018, the State Health Benefits
Plan has a new pharmacy benefit manager:
OptumRx, a division of United Healthcare.
OptumRx won the state contract through a
request-for-proposal process that did not
go through the State Health Benefits Design
Committee. That process is completely gov-
erned by the State Treasurer’s office. However,
there are several changes that our members
are now subject to that are more of an incon-
venience than anything else.
When we approved the national preferred
formulary for Express Scripts in 2017, several high-cost drugs
that had an equivalent were excluded in the coverage. Because
each pharmacy benefit manager has its own exclusionary list,
several of our members once again have to change from one
name brand to another, causing confusion and aggravation.
In each of these cases, the member should have received a let-
ter explaining the change ahead of time in order to ensure a
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smooth transition.
The next issue that you may or may not face is if a drug was
being prescribed outside of FDA guidelines. The prescription
will be modified to conform with those guidelines, which may
result in a change in dosage.
As a result, we also have had reports of copay fluctuations.
The reason for changes may be that the former pharmacy ben-
efit manager could have cut a deal with the drug manufacturer
that made the drug cheaper than a generic and allowed the ge-
neric copay for said drug. If OptumRx did not have that same
deal, you will now have to get the generic to retain the lower
copay.
During the past several months, you should have received no-
tifications if these situations were going to apply to you. If not,
OptumRx has asked that you call its help line at 844-368-8740,
the number on the back of your card, or go to www.optumrx.
com for help. Should you still have a problem, please ask your
State Delegate to contact the State PBA office for assistance. d