Premium Pharmacy Introduction

A: WHA has historically operated with a custom formulary design for Commercial and Individual lines of business. A decision was made to transition to Optum’s standard Premium and EHB formularies. In addition, WHA is refreshing our prescription benefit plans offered to streamline and align with market trends. 

A: The new Premium and EHB formularies deliver significant savings and value because they direct physicians and members from high-cost products when lower-cost drugs are available. It enables WHA to be market competitive and removes unnecessary spending for groups and members, while still providing quality coverage to WHA members.

A: Although there are drugs that may be excluded from formulary coverage, a standard formulary will organically drive members to lower costing products first, while allowing access to other drugs as needed. This ultimately results in lower overall health care costs while maintaining more affordable medication options for the majority of WHA members. 

A: Yes, one of the benefits of these new formularies is our ability to continue to maintain market competitive copayments (and coinsurance) for medications included in the formulary. Other benefits include more clarity or predictable coverage, whereas members can easily determine if their prescribed medication is in the formulary, reducing any confusion or potential disputes.

A: Both formularies aim to provide cost-effective choices while maintaining quality care and treatment: 

• Tier 1: Generic medications and lower-cost preferred brand name drugs
• Tier 2: Non-preferred generic drugs, preferred brand name drugs
• Tier 3: Non-preferred brand medications
• Tier 4: Specialty medications and other high-cost drugs, oral and injectable drugs, are tiered based on the Optum® Specialty Pharmacy drug list, which many may fall on this tier. 

There is mandatory utilization management in select drug categories. By simplifying and expanding from a 3-tier to a 4-tier formulary, we provide broad coverage and a minimal impact to our members. There’s simply more emphasis on managing our pharmacy benefits/prescription costs as we direct members to more cost-effective medications.

A: Overall, the benefits are focused on optimizing access to medications, improving health outcomes, and managing costs. These formularies include a list of carefully curated drugs essential for quality treatment:  

• Proven effectiveness. Medications are reviewed by the Pharmacy and Therapeutics (P&T) Committee and are determined to be safe and effective for their intended use.
• Cost-effectiveness (savings/choice). This formulary prioritizes cost-effective options and maintains choices, encouraging members to use lower-cost alternatives.
• Utilization management options. Utilization management programs may bring additional quality and savings opportunities.
• Prior Authorization and Step Therapy. Some drugs may require prior authorization or follow Step Therapy criteria. This ensures you have the most appropriate treatment while avoiding unnecessary expenses. 

A: The Premium and EHB formularies go into effect on January 1, 2025; plan benefit changes will go into effect upon the group’s renewal. The Preferred Drug Lists are available now on the OptumRx website here after selecting a 2025 formulary option. 

• Large Groups – Move to OptumRx Premium Formulary on 1/1/25.  We will continue to honor the group’s design and applicable copayments until the group renewal in 2025, when benefit plan changes will be effective.
• Small Group –Move to OptumRx Premium Formulary 1/1/25.
• Individual (Direct and Covered California) – Move to EHB Formulary 1/1/25. 

A: The majority of WHA members will experience no impact from this change/transition. 
Some member’s cost share may be impacted in one of two ways: 

1. Members who currently use a medication that will move to a lower tier (and therefore, will pay a lesser amount);
2. Members who currently use a medication that moves to a higher tier (and therefore, will have a higher cost) 
   Note: WHA will continue to cover that member’s medication if it was previously approved for coverage by the plan and continues to be safe and effective for the member, as determined by state law.