Assisting our clients with COVID-19 support
Frequently asked questions for OptumRx direct business
Providing medications to your members
At this time, OptumRx is not experiencing delays in dispensing most prescriptions from Optum-owned pharmacies (Optum Home Delivery, Optum Specialty, Optum Infusion Services, Avella, Genoa, Diplomat) related to COVID-19. OptumRx is using anticipatory analysis to determine if, and when, we need to expand operations to include advance dispensing, workforce management, medication access, and more - in ensuring we secure the medications needed for our patients and the ability to deliver those medications to members.OR
We’ve successfully managed challenging situations in the past including H1N1, Epi Pen shortage, Angiotensin II Receptor blocker drug shortages and numerous natural disasters across the country. We are monitoring the supply chain and actively working to maintain a reliable inventory. We’re also evaluating drug supplies going out to our pharmacies and ensuring our best practices and disaster recovery plans are implemented to meet the operational requirements of the organization.OR
Yes, similar to when we have an out-of-stock or recall situation today, we partner with our members and prescribers to identify alternatives and streamline the process to drive a faster turnaround and ensure our members have the therapy they need when they need it.OR
OptumRx is a member of Red Oak Sourcing, the largest generics buying group in the nation, which regularly meets with suppliers to discuss prospective and current market disruption. The Red Oak team has relationships at each step of the supply chain. For generics manufactured in India and China, Red Oak provided early supply intelligence allowing OptumRx to increase our supply of potentially impacted drugs and build inventory accordingly. We continue to monitor the supply chain on a daily basis.
When we have an out-of-stock or recall situation today, we partner with our members and prescribers to identify alternatives and streamline the process to drive a faster turnaround, and ensure our members have the therapy they need when they need it.OR
Hydroxychloroquine and chloroquine are used to treat a variety of conditions. Hydroxychloroquine is FDA-approved for the treatment of systemic lupus erythematosus, malaria and rheumatoid arthritis. Chloroquine is FDA-approved for the treatment and prevention of malaria and extraintestinal amebiasis.
In order to preserve a continued supply of medication for chronic conditions such as systemic lupus and rheumatoid arthritis while ensuring access to acute use for COVID-19, OptumRx will be implementing the following quantity limits:
- Hydroxychloroquine will be limited to 30 tablets within a 90-day time period with an automatic bypass (contingent therapy lookback edit) for members who have utilized at least a 60-day supply within the pastc120 days.
- Chloroquine will be limited to 30 tablets (or 40 tablets for 250 mg strength) within a 90-day time period.
If members require doses of hydroxychloroquine or chloroquine that exceed the quantity limit, their prescribers may complete a prior authorization following our standard process.OR
Due to the COVID-19 pandemic, there has been a surge in prescriptions for albuterol inhalers leading to an acute shortage in some areas. Manufacturers continue to produce albuterol inhalers but are struggling to keep up with the demand. To address the situation, OptumRx has temporarily changed the formulary status of non-formulary albuterol products, both brands (Proventil®, Ventolin®, ProAir®) and authorized brand alternatives, to facilitate member access to a broader array of albuterol-containing products. These actions also apply to levalbuterol products (Xopenenx® and generics). Effective April 10, 2020 for OptumRx standard formularies:
- Excluded albuterol and levalbuterol brand products are now covered in Tier 3.
- Excluded albuterol and levalbuterol generic products are now covered in Tier 1.
- Step therapy requirements for all albuterol and levalbuteral products on the OptumRx Select Formulary have been removed.
OptumRx will also delay the planned July 1, 2020 albuterol exclusions during the current shortage due to supply concerns. We will continue to monitor the supply chain and will move forward with the planned July 1, 2020 formulary updates once supply and access issues are resolved.OR
Consistent with government guidance, on Mar. 19 OptumRx extended existing prior authorizations (PAs) that were set to expire on or before May 1, 2020 to meet the needs of our clients’ members and limit the burden on a stressed provider network amid the COVID-19 outbreak. This was a one-time 90-day extension made to existing PAs for medications generally taken on a chronic basis.
After rigorous review of regulatory guidance and further assessment of our clients’ and members’ needs, OptumRx has made the decision not to extend this prior authorization policy further at the present time. The policy expired on May 1 except where required by applicable law. This means any prior authorizations requiring renewal starting May 2 are following our standard process.
Drugs with significant abuse potential (i.e., opioids) or those that are generally dosed for finite durations or intermittently (i.e., hepatitis agents, fertility agents) as identified by OptumRx continued to follow the normal process for renewals. Prior authorization requirements for medications that were newly prescribed also remained in place.OR
OptumRx will evaluate the need to relax required utilization management criteria including any required lab tests for those members impacted by a quarantine.OR
During the COVID-19 outbreak, when an existing patient calls to refill their specialty medication, Optum Specialty Pharmacy will offer patients a one-time, 90-day supply of key specialty medications instead of the traditional 30-day supply. This policy will be implemented by mid-April. This policy will not apply to patients newly initiating specialty therapy, or drugs within the following categories, which will remain limited to 30-day supply only:
- Acute medications
- Controlled substances
- Drugs subject to REMS programming requiring 30-day dispensing and monitoring
- Drugs with limited expiration dating
- Drugs where storage/handling issues would increase risk of waste
- Office-administered injectable/infusible therapies
- Drugs experiencing supply shortages
- Drugs dosed less frequently than once monthly
- Drugs whose monthly ingredient cost exceeds $10,000
Medications used in supportive care for the treatment of COVID-19 will be covered per the member’s current health plan benefit design. While there is no current treatment other than supportive care, OptumRx is monitoring the use of anti-viral products and production of a vaccine, and will continue to aggressively monitor CDC recommendations and outcomes of clinical studies.OR
Consistent with AMCP and other published policy, stockpiling is not encouraged because shortages are likely to increase when stockpiling occurs. We continue to assess if policy should change as CDC guidance evolves.OR
Retail pharmacy support
OptumRx communicates frequently with our retail pharmacy partners to ensure awareness and alignment on actions being taken due to the COVID-19 situation. We have removed certain restrictions at the present time.
- OptumRx will not subject retail pharmacies to mailing restrictions in accordance with CMS guidance.
- OptumRx has temporarily waived the signature requirement of mailed medications until a date to be determined.
- The delivery logs of impacted claims are to be documented with the verbiage “Impacted by COVID-19,” still allowing the signature log to be tied to the specific prescription (e.g., Rx# and fill date).
- Signature requirements for medications that are picked up at the pharmacy will also be waived, and signature logs of impacted claims are to be documented with the verbiage “Impacted by COVID-19” and initialed by the pharmacy staff.
OptumRx is working alongside other PBMs with the National Association of Boards of Pharmacy and state Boards of Pharmacy to find the best ways to navigate the current regulatory landscape and take appropriate measures to allow us to operate effectively for patient care.OR
In alignment with CDC guidance and all applicable federal, state and local public health requirements or recommendations, OptumRx has implemented a new component of our COVID-19 Response Policy to support members in accessing their medications at out-of-network pharmacies during this time.
OptumRx will provide a one-time network pharmacy override to access an out-of-network pharmacy upon pharmacy request when:
- An out-of-network pharmacy has stock of a covered prescription medication that is in short supply at a network pharmacy,
- An out-of-network pharmacy is in closer proximity than a network pharmacy to a member’s residence, as reported by the member, or
- An out-of-network pharmacy has capability to mail/deliver to the member’s home that is not provided by a network pharmacy.
The ability to offer out-of-network pharmacy network overrides was launched on April 10, 2020 and will remain in effect for 90 days, after which we will evaluate possible extensions. Specialty networks are not included in this policy since those medications are usually mailed.OR
We recommend members contact their local pharmacy directly to check if they offer delivery service or determine if their prescription can be filled by our OptumRx Home Delivery service.OR
We recommend members contact your local pharmacy directly to determine if they are open and filling prescriptions.OR
OptumRx Home Delivery Pharmacy support
OptumRx Home Delivery will continue to play its primary role in the supply of chronic maintenance medications and a limited number of acute medications. OptumRx will continue to work collaboratively with our network of 68,000 pharmacies which are best situated to dispense acute medications.OR
If a member is interested in switching a prescription to Home Delivery, they can check through the optumrx.com website to see if it is available. If a consumer is already on the phone, we will work with them through our normal onboarding process for new Home Delivery customers.OR
OptumRx Home Delivery does not charge members shipping fees. We already cover shipping costs for our members, with the exception of member-requested expedited shipping costs.OR
Call center support
Our first priority is to ensure members have access to the medications they need. At this time, OptumRx is experiencing high call volumes and longer than usual wait times. We are encouraging members to leverage our automated voice system or visit optumrx.com to immediately fill their prescriptions or check on order status. We are not experiencing any delays in shipments at this time.OR
At this time, OptumRx has no reason to suspect any concerns with medications being used in our pharmacies and is continuing to monitor the drug supply chain. OptumRx is firmly committed to the highest standards in selecting the vendors from which we source medications. Our prescription medications are purchased from approved sources that have implemented protections that comply with all FDA regulations as well as national standards of the Verified Accredited Wholesaler Drug program (VAWD).OR
If there is a COVID-19 vaccine
There is currently no approved vaccine for this virus. As soon as one is available, we will work to ensure access for our customers. We have a network of 68,000 pharmacies that can dispense vaccines and we will actively work with our pharmacies to administer any vaccines based on CDC recommendations and national availability.OR