Express Scripts 2013 Annual Report Download - page 9

9Express Scripts 2013 Annual Report
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. 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.
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.
Clinical Solutions. We also offer innovative clinically based intervention programs to assist and manage patient
quality of life, improve health outcomes and facilitate physician communication/education.
Our physician connectivity program facilitates well-informed electronic prescribing with real-time insight that
informs prescribers of a patient’s benefit, formulary information and medication history as they write a prescription.
RationalMed® evaluates medical, pharmacy and laboratory data to detect critical patient health and safety issues and gaps in
essential care which are then addressed through timely notification to physicians, pharmacies, patients and case managers.
ScreenRx® uses proprietary predictive models to detect adherent and nonadherent patients at risk for future nonadherence and
then proactively addresses the problem through interventions tailored specifically for that patient. ExpressAlliance® offers a
portfolio of patient care coordination services that enables client-authorized healthcare professionals to share a common view
of a patient’s health record and coordinate future patient outreach and counseling. Personalized medicine combines the latest
advances in pharmacogenomics testing with patient and physician outreach to help providers understand which drugs or
dosages work best for individual patients, empowering them to make more informed and cost-effective decisions that improve
patient care and safety.
Medicare Part D, Medicaid and Public Exchange Offerings. We support clients by providing several program
options: the Retiree Drug Subsidy program, which is offered by CMS to reimburse municipalities, unions and private
employers for a portion of their eligible expenses for retiree prescription drug benefits; the Employer Group Waiver Plan, a
group-enrolled Medicare Part D option for employers and labor groups; and the “PBM inside” service that offers drug-only and
integrated medical and Medicare Part D drug benefits to a number of Medicare Part D sponsors. As a PBM supporting health
plans, we provide prescription adjudication services in addition to a suite of required programmatic offerings such as a
Medication Therapy Management program, Explanation of Benefits for members using prescription services and a variety of
member communications related to their prescription benefit. We also offer an individual prescription drug plan which is
offered to beneficiaries in all 34 Medicare regions across the U.S., as well as Puerto Rico.
Our product revenues include premiums associated with our Medicare PDP risk-based products offerings. These
products involve prescription dispensing for beneficiaries enrolled in the CMS-sponsored Medicare Part D prescription drug
benefit. Two of our insurance company subsidiaries have been operating under contracts with CMS since 2006 and one since
2007. All three contracts currently offer several Medicare PDP options. The products involve underwriting the benefit, charging
enrollees applicable premiums, providing covered prescription drugs and administering the benefit as filed with CMS. We
provide two Medicare drug benefit plan options for beneficiaries, including a “standard Part D” benefit plan as mandated by
statute and a benefit plan with enhanced coverage that exceeds the standard Part D benefit plan, available for an additional
premium. We also offer numerous customized benefit plan designs to employer group retiree plans under the Medicare Part D
prescription drug benefit.
Our member website also supports pre-enrollment and post-enrollment activities on behalf of our Medicare PDP
and programs serving multiple clients. Prospective Medicare PDP participants and their caregivers can use the pre-enrollment
site’s Plan Compare tool to accurately project costs for all of their medications. The post-enrollment site allows members who
have signed up to receive a Medicare Part D benefit from either Express Scripts or one of our clients to securely manage all
aspects of their prescription program.
We support health plans that serve Medicaid populations by offering a pharmacy drug benefit. This business is
driven by state requirements and we earn revenues based on transaction-related activity. Common services include transitioning
members’ access to drugs as plan offerings change, generation of data to the state through encounter files and coordination of
benefits between states and other payors. Medicaid populations are expected to grow in states that choose to expand Medicaid
eligibility.