Express Scripts 2011 Annual Report Download - page 10

Express Scripts 2011 Annual Report
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networks of pharmacies that are customized for or under direct contract with specific clients. In addition, we have
contracted Medicare Part D provider networks to comply with CMS access requirements for the Medicare Part D
Prescription Drug Program.
All retail pharmacies in our pharmacy networks communicate with us online and in real time to process
prescription drug claims. When a member of a plan presents his or her identification card at a network pharmacy, the
network pharmacist sends certain specified member and prescription information in an industry-standard format through
our systems, which process the claim and send a response back to the pharmacy. The electronic processing of the claim
includes, among other things, the following:
• confirming the member’s eligibility for benefits under the applicable health benefit plan and any conditions or
limitations on coverage
• performing a concurrent drug utilization review and alerting the pharmacist to possible drug interactions and
reactions or other indications of inappropriate prescription drug usage
• updating the member’s prescription drug claim record
• if the claim is accepted, confirming to the pharmacy that it will receive payment for the drug dispensed according
to its provider agreement with us
• informing the pharmacy of the co-payment amount to be collected from the member based upon the client’s plan
design and the remaining payable amount due to the pharmacy
Home Delivery Services. As of December 31, 2011, we dispensed prescription drugs from our two home delivery
fulfillment pharmacies. In addition to the order processing that occurs at these home delivery pharmacies, we also operate
several non-dispensing order processing facilities and patient contact centers. We also maintain one non-dispensing home
delivery fulfillment pharmacy for business continuity purposes. Our pharmacies provide patients with convenient access to
maintenance medications and enable us to manage our clients’ drug costs through operating efficiencies and economies of
scale. Through our home delivery pharmacies, we are directly involved with the prescriber and patient and, as a result,
research shows we are generally able to achieve a higher level of generic substitutions, therapeutic interventions, and better
adherence than can be achieved through the retail pharmacy networks. Our direct relationship with patients also enables us
to leverage the principles of Consumerology®, our proprietary application of consumer marketing sciences and behavioral
psychology, to optimize health outcomes. As a result of these interactions, we believe we are able to improve patients’
healthcare decision-making and satisfaction with their prescription drug benefit.
Specialty Benefit Services. We operate several specialty pharmacies throughout the United States. These locations
provide patient care and direct specialty home delivery to our patients. We offer a broad range of healthcare products and
services for individuals with chronic health conditions and provide comprehensive patient management services. These
include services for physicians, health plan sponsors and pharmaceutical manufacturers to support the delivery of care, as
well as fertility services to providers and patients.
We provide specialty distribution services, consisting of the distribution of, and creation of a database of
information for, products requiring special handling or packaging, products targeted to a specific physician or patient
population and products distributed to low-income patients. Our services include eligibility, fulfillment, inventory,
insurance verification/authorization and payment.
Patient Care Contact Centers. Although we contract with health plans and employers, the ultimate recipients of
many of our services are the members and employees of these health plans and employers. We believe client satisfaction is
dependent upon patient satisfaction. Domestic patients can call us toll free, 24 hours a day, 7 days a week, to obtain
information about their prescription drug plan from our trained patient care advocates and pharmacists.
Benefit Plan Design and Consultation. We offer consultation and financial modeling to assist our clients in
selecting benefit plan designs that meet their needs for member satisfaction and cost control. The most common benefit
design options we offer to our clients are:
• financial incentives and reimbursement limitations on the drugs covered by the plan, including drug formularies,
tiered co-payments, deductibles or annual benefit maximums
• generic drug utilization incentives
• incentives or requirements to use only certain network pharmacies or to order certain maintenance drugs (e.g.,
therapies for diabetes, high blood pressure, etc.) only through our home delivery pharmacies
• reimbursement limitations on the amount of a drug that can be obtained in a specific period
• utilization management programs such as step therapy and prior authorization, which focus the use of medications
according to clinically developed algorithms