Optima Health to Implement New PBM

Effective January 1, 2023, Optima Health will change our pharmacy benefit manager (PBM) from OptumRx®️ to Express Scripts®️ for commercial, Medicare, and Medicaid plans.

Here is what you need to know:

  • Members should experience a seamless transition; all active pre-authorizations will automatically transfer to the new vendor.
  • Prior to January 1, 2023, we will issue new Optima Health member ID cards to members with our pharmacy benefit to reflect the new pharmacy vendor information.
  • If applicable, members will receive a notification letter in advance of any formulary or network changes. As always, members should refer to their benefits for information regarding medication tiers and costs.
  • We will continue to use Proprium Pharmacy for specialty and tier 4 medications.
  • Optima Medicare Providers: Beginning January 1, coverage determinations and appeals and grievances will be managed by Express Scripts. Currently, those functions are managed by OptumRx.

For more information, please review our frequently asked questions document. If you have questions, please contact your Network Educator at 1-877-865-9075, option 2.