ESI Enforcing Mail Order and Formulary Limits
PAAS recently became aware of Express Scripts (ESI) enforcing their mail order and formulary compliance limitations. Several pharmacies have received Cease & Desist notices from ESI and even one contract termination notice.
ESI is using patient address information to make assumptions as to which claims are being mailed outside of the pharmacy’s service area because ESI does not allow mail order under a standard retail contract. The notices are not indicating what ESI is using for service area. Notices have been issued for assumed mail order claims of as little as 10% of total ESI claims. Pharmacies may need to provide proof that claims were delivered or picked up to avoid future contract termination.
ESI also is requiring that pharmacies use “best efforts to achieve formulary compliance.” Having a high percentage of non-formulary or brand drugs may be considered a violation of their Provider Manual. One of the notices specifically identified a high percentage of claims for products manufactured by Horizon Pharma. ESI stated that this was evidence that the pharmacy was not operating as a traditional retail pharmacy that dispenses a variety of drugs.