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Express Scripts Announcement

On Tuesday, June 3, 2014, Express Scripts (ESI) announced the launch of its comprehensive compounding management strategy.

Key highlights:

  • This strategy will affect all patients in employer plans for which ESI is the pharmacy benefits manager
    • No health plans, public employees or Medicare/Medicaid lives will be affected
  • ESI is including every employer plan in the program; therefore, employers must opt out to be excluded from the program

What is in the ESI compounding management strategy?

  • ESI will target 1,000 products (APIs and non-APIs)
    • ESI believes these 1,000 products account for 95% of compounding spend under ESI employer plans
    • ESI is claiming that this strategy will ELIMINATE 95% of compounding spend for clients who accept and fully implement the program
  • These products will be moved to a non-formulary tier, meaning that the patient will have to pay the FULL cost for the compound out-of-pocket, or go through a very rigorous appeals process to have it covered
    • This process will be difficult for patients and prescribers to navigate, making it easier for prescribers to switch the patients to a different product
  • The 1,000 products will constitute an “EXCLUDED” list, which ESI will manage
  • ESI will continue to review and monitor ALL compounding ingredients based on cost, AWP increase, status (API vs. OTC), etc., for inclusion in the excluded list
  • ESI will also create an “INCLUDED” list of products that are exempt from exclusion based on specific requirements such as short supply, necessity, etc.
    • Examples include: Tamiflu, HRT and progesterone
  • Both lists will be managed in accordance with FDA alerts and client requests

How is ESI planning to roll this out?

  • ESI plans to roll out its compounding management program  in three phases:
    • Phase 1 – Early adopters switch date is July 15, 2014 without patient pre-notification
    • Phase 2 – Patients notification on July 15 with a 60-day pre-notification and switch on September 15, 2014
    • Phase 3 – Union groups and large employers switch date is January 1, 2015
  • ESI plans to communicate to pharmacies soon to advise them of the changes and inform them how to verify whether a product is covered or not
  • Pharmacies will receive instructions but will not be allowed to dispute the program

What is PCCA doing about this?

  • PCCA is focused on protecting the profession of compounding pharmacists and we’re in the process of developing next steps
  • We are also talking with industry associations about possible coordinated approaches
  • As updates are available, we’ll be communicating these to you via email, the Apothagram and at  protectmycompounds.com

What can members do today?

  • Stay informed