Express Scripts Reminds Pharmacies of Copay Collection Obligations

Express Scripts sent a memo to network providers the middle of October, pertaining to copayment collection, to ensure requirements are being met in the appropriate manner. There is emphasis placed on network providers being adherent to Section 2.3 of the ESI Provider Manual stating “Network Providers agree that it shall collect the full Copayment from Members, and that the Copayment is not changed or waived unless required by law”. The memo also discusses what documentation is required in case of an audit, which includes credit card receipt, point of sale (POS) receipt which reflects cash payment, and/or copy of cancelled check.

As a reminder, Express Scripts, in addition to other PBMs, reserve the right to terminate your provider status if failure to collect copays is discovered.

PAAS Tips:

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  • Refer to the Provider Manuals of other PBMs regarding their copayment policies. The top PBMs and their corresponding Provider Manual sections are listed below:
    • Caremark: Section 3.03.04
    • Prime Therapeutics: Section 3: Claims Processing
    • OptumRx: V. Processing Claims, Section Q: Collection of Members Cost-Sharing Amount
    • Elixir: mentioned in sections pertaining to “suspensions and terminations”, and “reimbursement and cost share”
  • Review the following Newsline articles:
  • PAAS Fraud, Waste, and Abuse and HIPAA Compliance members can reference Section 4.1.5 within their Policy and Procedure Manual for a copay collection policy which corresponds to the response to question 12 on the policy and procedure manual questionnaire.

Meredith Thiede, PharmD
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