OptumRx Makes Utilization Management Changes for 2023

OptumRx now requires prior authorization for 16 products, including 11 that are used to treat patients with diabetes.

OptumRx has made a number of utilization management changes — requiring prior authorization or step therapy and putting quantity limits — on its formularies effective Jan. 1, 2023. (See table below.)

The PBM now requires prior authorization for 16 products, including 11 that are used to treat patients with diabetes. OptumRx officials have not responded to requests for comments on the changes.

Among the insulins requiring prior authorization are insulin aspart, NovoLog ReliOn (insulin apart), and insulin lispro. Insulin aspart is the generic of Novolog, which has an average retail price of $176.75 for one vial, according to GoodRx. ReliOn is a private-label version of NovoLog that is manufactured by Novo Nordisk and sold at Walmart and Sam’s Club. Insulin lispro is the generic of Humalog and has an average retail price of $153.42 for one vial, according to GoodRx.

Eight of the diabetes products that now require prior authorization are part of the GLP-1 agonists class of drugs used to treat patients with type 2 diabetes. GLP-1 is a hormone that is produced in the small intestine. These products stimulate insulin secretion and may help with weight loss.

GLP-1 agonists are now the preferred drugs to add to a patient’s regimen when oral metformin by itself is not enough to meet the patient’s hemoglobin A1c goal. They have been found to be better than short-acting agents and better than insulin, lowering hemoglobin A1c by about 1%. And GLP-1 receptor agonists are recommended as either first-line or second-line therapy in patients who have established atherosclerotic cardiovascular disease, high risk of atherosclerotic cardiovascular disease, chronic kidney disease, or heart failure.

Among the GLP-1 products that OptumRx now requires prior authorization are:

  • Sanofi’s Adlyxin (lixisenatide), an injectable for adults with an average retail price of $702.35 for one carton, according to GoodRx.
  • AstraZeneca’ Bydureon BCise (exenatide), an injectable for adults and children 10 years and older. AstraZeneca has partnered with GoodRx to offer this product discounted, with an average price of $816.10 for a carton of four pens.
  • Lilly’s Mounjaro (tirzepatide), an injectable for adults, which has an average retail price of $1,173.55 for one carton of four pens.
  • Novo Nordisk’s Ozempic (semaglutide), an injectable for adults, which has an average retail price of $1,027.10 for 1 prefilled pen.
  • Novo Nordisk’s Rybelsus (semaglutide), an oral for adults, which has an average of $1,061.47 for 30 tablets.
  • Lilly’s Trulicity (dulaglutide), an injectable for adults. GoodRx lists the lowest price as $771.11 for four pens.
  • Novo Nordisk’s Victoza (liraglutide), an injectable for adults and children 10 years and older, which has an average retail price of $1,142.89 for three pens.

In terms of step therapy, OptumRx has placed 22 branded drugs for attention-deficit/hyperactivity disorder (ADHD) as step 2 therapies, with generics as step 1. Step therapy requires patients to use lower cost medications before trying the more expensive drug.

Among the branded drugs now that are step include: Adderall (amphetamine salt combo), Concerta (methylphenidate ER), Focalin (dexmethylphenidate), Mydayis, and Ritalin (methylphenidate). In addition to generics, OptumRx also includes Takeda’s Vyvanse (lisdexamfetamine) as a step 1 therapy. GoodRx is showing a retain price as low as $354.50 for 30 capsules of Vyvanse.