Upcoming 2021 OptumRx Formulary Changes

Renee Rayburg, RPh
September 21, 2020

Looking toward 2021, OptumRx has announced its formulary changes effective January 1, 2021. These changes will include a combination of downtiers, uptiers, and exclusions with the number of changes varying across the type of formulary in place. To “preserve quality, affordability, and access to care,” and OptumRx has released its list of 50 new exclusions for 2021, and 15 add backs. Looking across the PSG book of business, this is expected to represent 5.8 percent impact on members and 2.6 percent impact on cost.

The 2021 changes include:

OptumRx – Premium Formulary #
New Exclusions for 2021 50
Number of Specialty Drugs 6
Preferred to Non-Preferred 10
Number of Specialty Drugs 4
Positive Changes (add backs) 15
Member Impact % 5.8%
Cost Impact % 2.6%


The most notable downtier, which moves a product to a lower tier making it more affordable, is Contour® Next, moving from excluded status to the only preferred blood glucose meter and test strip product for people with diabetes.  The current preferred product, OneTouch®, will move to excluded. New Contour Next meters will be provided at no cost to members.

OptumRx considers a medication for exclusion when it “offers no clinical value over other options in its class.” Changes for 2021 include 129 exclusions, including Evzio®, a $4,000 Naloxone auto-injector for suspected opioid overdoses and Livalo®, the only remaining branded statin for lowering cholesterol.

Like other pharmacy benefit managers (PBMs), OptumRx is moving forward with a generic only rescue inhaler strategy by excluding Proventil®, Ventolin®, and ProAir® HFA products and preferring the generic equivalent, albuterol HFA. While this change may affect many members, the disruption should be minimal.

Drug exclusions will also include select specialty drugs. Rebif® (interferon beta-1a) injection for multiple sclerosis will be excluded with Avonex® or Betaseron® as preferred alternatives. Udenyca®, a biosimilar to Neulasta®, will be excluded with brand Neulasta and Ziextenzo® as preferred alternatives. Exondys 51®, an IV infusion for Duchenne muscular dystrophy (DMD), will be excluded. However, this drug is not typically billed through the pharmacy benefit, so it could still be available for coverage through the medical benefit.

Truvada® will be excluded as part of the 2021 changes, since a generic version of Truvada (emtricitabine/tenofovir) can be manufactured in the U.S. as of September 30, 2020. In addition to Descovy®, the only two drugs indicated for HIV-1 pre-exposure prophylaxis (PrEP) are both manufactured by Gilead. Both will be excluded in anticipation of a lower-cost generic Truvada alternative. Gilead has successfully converted 43 percent of patients using Truvada for PrEP to Descovy, which both have a monthly list price of $1758, to retain brand market share for PrEP use. However, coverage of the only Truvada generic remains consistent with OptumRx’s commitment to affordability.

OptumRx has added 80 non-essential drugs to their Vigilant Drug List for exclusion as part of the 2021 changes, which offers continued cost savings. For plan sponsors who do not have the Vigilant Drug List in place, they offer a “Me-Too” step therapy program for a subset of drugs in an attempt to promote the use of the lower-cost alternatives.

In addition to the 2021 formulary changes, OptumRx is also implementing updates to its utilization management programs.  Highlights of the updates include:

  • Quantity limits for the acute treatments of hereditary angioedema(HAE): Berinert®, Firazyr®, Kalbitor®, and Ruconest®. However, there was no mention of any strategies to prefer the use of generic Firazyr (icatibant), whose list price is about half of the $33,000 list price for brand Firazyr.
  • Quantity limit of one unit per 56 days for Stelara® to align with the proper frequency of treatment. As they mentioned, Stelara was sometimes filled more frequently than recommended.
  • Prior authorization for Beovu®, Eylea®, and Macugen®, which requires the use of Lucentis® or compounded Avastin® These products used to treat certain eye conditions are typically administered in the physician office, so most often are billed through the medical benefit.

For current PSG clients, reach out to your account team for assistance and questions. OptumRx will provide specific details on how the formulary changes impact individual groups in the next week. Reach out to [email protected] for more information.

Up next: Learn more about the Express Scripts formulary changes for 2021.

Renee Rayburg helps lead Artemetrx services in Clinical Consulting with more than 30+ years in pharmacy and medical benefit management to support our health plan sponsors, providers, and patients.  Her thought leadership and passion for specialty pharmacy continues to influence the market, including important changes to specialty vendor clinical management products for the betterment of clients.