Optum Rx, a pharmacy benefit manager owned by one of the country’s largest insurance companies, UnitedHealth Group, has added a new, much-anticipated pain drug to some of its commercial formularies.
Sold as Journavx, the drug received U.S. approval in late January as a treatment for the short-lived “acute” pain typically felt after an operation or accident. Journavx works differently than other available medications, and its developer, the biotechnology juggernaut Vertex Pharmaceuticals, has positioned it as an important, non-opioid option for pain management.
While doctors have welcomed this additional tool, and some analysts see it as a multibillion-dollar product, substantial commercial barriers could constrain patient access as well as sales. Cheap opioids have long dominated the pain drug market. At a list price of $31 a day, Journavx is many times more expensive than generic versions of drugs like hydrocodone.
Ahead of the drug’s approval, Stuart Arbuckle, Vertex’s chief operations officer, said price and access were the biggest issues stakeholders had raised in discussions on Journavx. Still, he said then that conversations with insurers were going well.
“We’re encouraged Optum has added Journavx to its formulary, reflecting the unmet need for new treatment options and the promise of Journavx in acute pain, and we continue to work with them and other payers to ensure broad availability,” Heather Nichols, a Vertex spokesperson, said in a statement.
Optum’s move, first reported by Bloomberg, appears to be the first significant, public update about Journavx coverage from a major commercial payer. Other healthcare giants, including CVS, Humana and Cigna, either declined or didn’t immediately respond to requests for updates on their coverage plans.
The team that crafts the list of prescription drugs that Optum covers is still evaluating the clinical data underpinning Journavx “and will make a recommendation on formulary placement soon,” according to Elizabeth Hoff, a spokesperson for Optum’s pharmacy care services division.
“In the interim, Journavx was added to our standard commercial formularies to allow immediate access to a non-opioid option for moderate-to-severe pain in the acute setting,” Hoff added.
Optum has, for now, put Journavx on “Tier 3” of its formulary, which is designated for “higher-cost brand name” drugs along with some generics. Optum notes that using lower tier or “preferred medications” can help lower out-of-pocket costs for patients.
Not long before Journavx’s approval, analysts at the investment firm Cantor Fitzgerald said they spoke to a senior director of product development at UnitedHealth Group. According to analyst Olivia Brayer, the director expected Journavx to receive broad coverage because insurers are under pressure to cover non-opioid pain medications.
He also did not anticipate Journavx having to go through “step therapy,” a controversial practice in which patients must “fail” on cheaper drugs before an insurer agrees to cover pricier medicines.
In a note to clients, Leerink Partners analyst David Risinger described UnitedHealth’s initial coverage as “encouraging.”
“Bottom line: We are pleased to see a major PBM cover Journavx ahead of its launch for acute pain,” Risinger wrote.
Medicaid plans in two states — New York and Arkansas — have also put policies in place for Journavx.