Express Scripts 2011 Annual Report Download - page 11

Express Scripts 2011 Annual Report 9
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• evidence-based, behavior-centric Consumerology® programs that drive adoption of cost-effective drug mix,
improved therapy adherence and increased use of home delivery
The client’s choice of benefit design is entered into our electronic claims processing system, which applies the
plan design parameters as claims are submitted and provides visibility to the financial performance of the plan.
Drug Formulary Management, Compliance and Therapy Management Programs. Formularies are lists of drugs to
which benefit design is applied under the applicable plan. We have many years of formulary development expertise and
maintain an extensive clinical pharmacy department.
Our foremost consideration in the formulary development process is the clinical appropriateness of the particular
drugs. In developing formularies, we first perform a rigorous assessment of the available evidence regarding each drug’s
safety and clinical effectiveness. No new drug is added to the formulary until it meets standards of quality established by
our National Pharmacy & Therapeutics (―P&T‖) Committee – a panel composed of 19 independent physicians and
pharmacists in active clinical practice, representing a variety of specialties and practice settings, typically with major
academic affiliations. We fully comply with the P&T Committee’s clinical recommendations. In making its clinical
recommendation, the P&T Committee has no information regarding the discount or rebate arrangement we might negotiate
with the manufacturer. This is designed to ensure the clinical recommendation is not affected by our financial
arrangements. After the clinical recommendation is made, the drugs are evaluated on an economic basis to determine
optimal cost effectiveness.
We administer a number of different formularies for our clients. The use of formulary drugs is encouraged through
various benefit design features. For example, historically, many clients selected a plan design that included an open
formulary in which all drugs were covered by the plan. Today, a majority of our clients select formularies that are designed
to be used with various financial or other incentives, such as three-tier co-payments, which drive the selection of formulary
drugs over their non-formulary alternatives. Some clients select closed formularies, in which benefits are available only for
drugs listed on the formulary. Use of formulary drugs can be encouraged in the following ways:
• through plan design features, such as tiered co-payments, which require the member to pay a higher amount for a
non-formulary drug
• by applying the principles of Consumerology®, our proprietary approach that combines principles of behavioral
economics and consumer psychology with marketing strategies to effect positive behavior change
• by educating members and physicians with respect to benefit design implications
• by promoting the use of lower-cost generic alternatives
• by implementing utilization management programs such as step therapy and prior authorization, which focus the
use of medications according to clinically developed algorithms
We also provide formulary compliance services to our clients. For example, if a doctor has prescribed a drug that
is not on a client’s formulary, we notify the pharmacist through our claims processing system. The pharmacist may then
contact the doctor to attempt to obtain the doctor’s consent to change the prescription to the appropriate formulary product.
The doctor has the final decision-making authority in prescribing the medication.
We also offer innovative clinically based intervention programs to assist and manage patient quality of life, client
drug trend, and physician communication/education. These programs encompass comprehensive point of service and
retrospective drug utilization review, physician profiling, academic detailing, prior authorization, disease care management,
and clinical guideline dissemination to physicians.
Since implementing Consumerology® in 2008, we have further developed and refined the methods we use in an
effort to improve how members use their pharmacy benefit, stay compliant with their medications and save money for
themselves and their plan sponsors. Through Consumerology®, we believe we are enabling better health and value by
driving positive clinical behavior. We use behavioral economics to develop new approaches in an effort to encourage
adoption of generics and lower-cost brands, better therapy adherence and greater use of home delivery. Through our
Consumerology® Advisory Board, we continue to gain insight into how patients make decisions about healthcare. We
believe the interventions that have resulted from our test-and-learn process have yielded improvements for our clients and
their members.
Information Reporting and Analysis Programs. Through the use of sophisticated information and reporting
systems we are better able to manage the prescription drug benefit. We analyze prescription drug data to identify cost trends
and budget for expected drug costs, assess the financial impact of plan design changes and assist clients in identifying
costly utilization patterns through an online prescription drug decision support tool.