UnitedHealth Group’s pharmacy benefit manager Optum Rx has become the first major insurer to provide coverage for Vertex Pharmaceuticals’ newly approved pain medication Journavx, marking a significant milestone for the non-opioid treatment option.
The interim decision places Journavx on select commercial formularies while Optum continues its formal evaluation process. The medication, which received FDA approval in January 2025, is designed to treat acute pain following surgery or injury using a novel mechanism of action that differs from existing pain treatments.
According to Elizabeth Hoff, an Optum pharmacy care services spokesperson, the drug has been temporarily added to standard commercial formularies to provide immediate access to a non-opioid alternative for moderate-to-severe acute pain. The clinical review team is still analyzing Journavx’s data before making final
recommendations on its formulary placement.
Currently, Journavx occupies Tier 3 status on Optum’s formulary, a category typically reserved for higher-priced branded medications and some generics. The company notes that patients may face lower out-of-pocket expenses by choosing preferred medications from lower tiers.
The coverage decision comes amid discussions about the drug’s pricing and accessibility. At $31 per day, Journavx’s list price significantly exceeds that of generic opioids, which have traditionally dominated pain management. However, Vertex’s Chief Operations Officer Stuart Arbuckle had previously indicated that while pricing and access were key concerns among stakeholders, discussions with insurance providers were progressing positively.
Vertex spokesperson Heather Nichols expressed optimism about Optum’s decision, stating that it acknowledges both the unmet need for new pain treatments and Journavx’s potential in acute pain management. The company continues to engage with Optum and other insurers to expand availability.
Investment analysts have viewed this development favorably. Leerink Partners analyst David Risinger characterized UnitedHealth’s initial coverage as “encouraging.” Earlier discussions between Cantor Fitzgerald analysts and a UnitedHealth Group senior director suggested that Journavx would likely receive broad coverage due to increasing pressure on insurers to cover non-opioid pain medications. The director also indicated that step therapy requirements, which typically require patients to try less expensive alternatives first, were not expected for Journavx.
Other major healthcare companies, including CVS, Humana, and Cigna, have not yet announced their coverage plans for the medication. However, Medicaid programs in New York and Arkansas have already established policies regarding Journavx coverage.
The introduction of Journavx represents a significant development in pain management, offering healthcare providers a new tool beyond traditional opioid medications. While analysts project it could become a multibillion-dollar product, its commercial success will largely depend on insurance coverage and patient access. The drug’s higher price point compared to generic opioids presents a potential barrier to widespread adoption, making insurance coverage decisions
particularly crucial for its market penetration.
Vertex’s strategy appears focused on positioning Journavx as an important alternative in pain management while working to secure broad insurance coverage. The company’s ongoing discussions with various payers suggest a concentrated effort to ensure the medication becomes widely available to patients seeking non-opioid pain relief options.