A few of our customers have received an Express Scripts Quality Based Medicare Network contract for 2018, with the option to opt out. But some have not, which begs the question, why hasn’t everyone received it?

This contract outlines the new Express Scripts performance program, but does not designate which Medicare plans will be part of this network.

The contract allows 30 days to opt out of the Quality Based Network. If you do opt out, your pharmacy will not be contracted with any of the ESI plans adopting the Quality Based Network and won’t be eligible to contract with these plans until 2019.

The performance measurements are referred to as “CMS adherence measures” but are not detailed beyond this. Speciality pharmacies will have different measures and are referred to as “adherence measures related to speciality diseases states.”

Based upon these unknown performance measurements, there are four tiers and their corresponding retroactive performance adjustments.

The tiers are:

Top Performers – Tier 1 (Top 1%) - 0% off AWP

High Performers – Tier 2 (Top 2-15%)- 2% off AWP

Standard Performers – Tier 3 (Middle 60%)- 4% off AWP

Low Performers – Tier 4 (Bottom 25%) - 6% off AWP

Even if it is not referred to as a DIR fee, it will essentially act like one.

What can an independent pharmacy do?

Lend support to NCPA’s legislation banning retroactive clawbacks.

80% of Medicare beneficiaries are not enrolled in the least expensive plan for their specific drug list. That being said, there is likely a more mutually beneficial plan available now, for both the patient and the pharmacy. Remember, dual eligible patients can change plans at any point in the year.

In iMedicare you can view patients on ESI plans by clicking on “All patients” on your iMedicare account homepage and filtering to the appropriate BIN. Two common BINs for Express Script plans are 610014 and 003858. When iMedicare identifies the new Express Scripts adherence measurements it will reflect this within the adherence report and flag patients that are negatively impacting your DIR fees. If your pharmacy software has a live integration with iMedicare you will receive DIR Intervention notifications when you fill prescriptions for patients who fall under the requisite adherence threshold, with the option to schedule a refill reminder right from the notification.

At this time it is unclear which Part D plans will participate in this new performance network.

Be on the lookout for any correspondence from Express Scripts and we will be sure to send an update as soon as we have more information.