On Tuesday, June 3, 2014, Express Scripts (ESI) announced the launch of its comprehensive compounding management strategy.
- 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
- We will be updating members via email and at protectmycompounds.com on PCCA next steps and strategies