Express Scripts 2014 Annual Report Download - page 11

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Express Scripts 2014 Annual Report
processingthroughtheprescriptiondrugbenefit.Weprovideourclientsatoolsetdesignedtomanagetotalspecialtyspend
regardlessofwhichbenefitthedrugisprocessedthrough.Ourcapabilitiesincludeguaranteeingsavingsthroughmedical
benefitmanagementservices,ensuringthesafeandappropriateuseofhigh-costspecialtydrugs,redirectingpatientsand
medicationstothelowest-costandmostappropriatechannel,verifyingclaimsarepaidatthecontractedrate,improving
opportunitiestoachieverebatesand,whereclinicallyappropriate,movingdrugcoveragefrommedicaltopharmacybenefitand
tolower-costsitesofcare.
Retail Network Pharmacy Administration.Wecontractwithretailpharmaciestoprovideprescriptiondrugsto
membersofthepharmacybenefitplanswemanage.IntheUnitedStates,PuertoRicoandtheVirginIslands,wenegotiatewith
pharmaciestodiscountthepricesatwhichtheyprovidedrugstomembersandmanagenationalandregionalnetworksthatare
responsivetoclientpreferencesrelatedtocostcontainment,convenienceofaccessformembersandnetworkperformance.We
alsomanagenetworksofpharmaciescustomizedfororunderdirectcontractwithspecificclients.Inaddition,wehave
contractedpharmacyprovidernetworkstocomplywithCMSaccessrequirementsfortheMedicarePartDPrescriptionDrug
Program(“MedicarePartD”).
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,prescriberandprescriptioninformationinanindustry-standardformatthroughour
systems,whichprocesstheclaimandsendaresponsebacktothepharmacywithrelevantinformationtoprocessthescript.
Benefit Design Consultation.Weconsultwithourclientsonhowbesttostructureandleveragethepharmacy
benefittomeettheirobjectivesforaffordablebenefits,providingaccesstoneededcarewhileeliminatingwaste.Wesupportour
clientsindeterminingthescopeandconditionsofcoverageandofferingincentivesformembersandtheirproviders.Weadopt
programsthatdrivesafer,moreeffectiveandmoreaffordableuseofprescriptiondrugs.
Drug Utilization Review.Ourelectronicclaimsprocessingsystemenablesustoimplementsophisticated
interventionprogramstomanageprescriptiondrugutilization.Thesystemcanalertthepharmacisttodrugsafetyconcerns,
genericsubstitutionandtherapeuticinterventionopportunities,aswellasformularyadherenceissues,andcanalsoadminister
priorauthorization,steptherapyprotocolprogramsanddrugquantitymanagementatthetimeaclaimissubmittedfor
processing.Ourclaimsprocessingsystemalsogeneratesadatabaseofdrugutilizationinformationthatcanbeaccessedatthe
timeaprescriptionisdispensed,onaretrospectivebasistoanalyzeutilizationtrendsandprescribingpatternsformore
intensivemanagementofthedrugbenefit,andonaprospectivebasistohelpsupportpharmacistsindrugtherapymanagement
decisions.
Drug Formulary Management. Formulariesarelistsofdrugstowhichbenefitdesignisapplied.Incombination
withthebenefitdesign,theformularymaybeusedtocommunicateplanpreferencesandtodeterminewhetheraparticulardrug
iscovered.Ifcovered,theformularywilldeterminetowhatextentitiscovered.Ourformularymanagement servicessupport
clientsinchoosingandmaintainingformulariesthatbestmeetplanobjectivesforaccess,safetyandaffordability.Further,our
formularymanagementservicesassistpatientsandphysiciansinchoosingclinicallyappropriate,cost-effectivedrugsfora
givencondition,formularyandplandesign.
Weadministermanydifferentformulariesonbehalfofourclients,includingstandardformulariesdevelopedand
offeredbyExpressScriptsandcustomformulariesforwhichweplayamorelimitedrole.Themajorityofourclientsselect
standardformularies,governedbyourNationalPharmacy&Therapeutics(“P&T”)Committee,apanelcomposedof
independentphysiciansandpharmacistsinactiveclinicalpractice,representingavarietyofspecialtiesandpracticesettingsand
typicallywithmajoracademicaffiliations.Mostclientschooseformulariesdesignedtobeusedwithfinancialincentives,such
asthree-tierco-payments,whichdrivepreferentialselectionofplan-preferredgenericsandbrandeddrugsovertheirnon-
formularyalternatives.Someclientsselectclosedformularies,inwhichcoverageisavailableonlyforthosedrugslistedonthe
formulary.
ExpressScripts’standardformulariesaregovernedbydecisionsoftheNationalP&TCommittee.Indeveloping
theseformularies,theforemostconsiderationisthesafetyandeffectivenessofthedrugsbeingevaluatedinrelationtoavailable
alternatives.Inmakingformularyrecommendations,theP&TCommitteeconsidersthedrug’ssafetyandefficacy,withoutany
informationonorconsiderationofthecostofthedrug,includinganydiscountorrebatearrangementwemightnegotiatewith
themanufacturer.Thisprocessisdesignedtoensuretheclinicalrecommendationisnotaffectedbyourfinancialarrangements.
WefullycomplywiththeP&TCommittee’sclinicalrecommendationsregardingdrugsthatmustbeincludedorexcludedfrom
theformularybasedontheirassessmentofsafetyandefficacy.WheretheNationalP&TCommitteeisindifferentastowhether
aparticulardrugmustbeincludedorexcludedfromtheformulary,thedrugsareevaluatedonaneconomicbasisinrelationto
alternativestodeterminetheoptimalcompositionoftheformulary.
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