News
Lowest Net Cost Formulary Update Bulletin - Effective January 1, 2026
November 3, 2025
The Changes in This Update Apply to all Groups That use OptumRx
The majority of these updates include decisions that occurred as a result of the August 2025 Pharmacy and Therapeutics Committee (P&T) meeting. Members negatively impacted by these changes will be sent a notification letter in November.
FORMULARY UPDATES
Additions
These drugs will be added to the formulary effective Jan. 1, 2026:
Product | Drug Class/Category | Utilization Management Programs | Formulary Status |
| Ensacove | Cancer | PA | Non-Preferred Specialty |
| Gomekli | Cancer | PA | Non-Preferred Specialty |
| Grafapex | Cancer | PA | Non-Preferred Specialty |
| Onapgo | Parkinson’s | PA/QL | Non-Preferred Specialty |
| Qfitlia | Hemophilia | ST/QL | Non-Preferred Specialty |
| Romvimza | Cancer | PA | Non-Preferred Specialty |
Diabetes Preferred Test Strip Update
Effective Sept. 15, 2025, Contour and Accu-Chek were added as preferred diabetic test strips joining OneTouch, which was already preferred. As a result, all three brands, OneTouch, Contour and Accu-Chek, will remain preferred on the formulary until Dec. 31, 2025.
Upcoming Change:
Effective Jan. 1, 2026, as part of the broader formulary updates, OneTouch test strips will move to non-preferred status on the formulary and will require prior authorization. Contour and Accu-Chek test strips will be the preferred options on the formulary. Member disruption communications will be included with the overall Jan. 1, 2026 formulary change notifications.
Utilization Management Programs
Quantity Limits
Effective Nov. 1, 2025, the following products will have new quantity limits:
Drug | New Quantity Limits |
| Vyvgart Vial | 12 vials (240 mL) per 50 days |
| Vyvgart Hytrulo Vial | 4 vials (22.4mL) per 28 days |
| Vyvgart Hytrulo Prefilled Syringe | 4 syringes (20 mL) per 28 days |
Moving from Specialty to Non-specialty
Effective Nov. 1, 2025, the following products will move from specialty to non-specialty status:
- Entecavir tablets
- Baraclude tablets
- Baraclude solution
Medical Benefit Only
The following specialty drugs became eligible for coverage under the medical benefit effective Oct. 1, 2025:
HCPCS/J-CODE | Drug Name |
| J7173 | Alhemo* |
| Q5158 | Bomyntra/Conexxence |
| C9306 | Emrelis |
| C9305 | Imaavy |
| Q5154 | Omlyclo |
| J7174 | Qfitlia* |
| Q5157 | Stoboclo/Osenvelt |
| Q5156 | Avtozma |
| J9011 | Datroway |
| J3403 | Encelto |
| J1809 | Nulibry |
| Q5159 | Ospomyv/Xbryk |
| J1961 | Sunlenca |
| Q5155 | Yesafili |
| * Medical coverage subject to plan design and inability to self-administer; most members will access via pharmacy benefit. | |
Additional Update:
Apretude - Prior authorization requirements have been removed.