July 29, 2022
New ESI Tricare Contract Has
15-Day Opt-in for '23 Network
Express Scripts Incorporated (ESI) is sending out a Tricare network enrollment alert via FAX to some of our members. The faxed alerts we have seen set a 15-day response deadline from the date the alert FAX is received. We do not know if ESI has communicated with all pharmacies by FAX or with some by other methods, and we do not know if the notifications were sent out to all Tricare pharmacies at the same time

The alert states that pharmacies must sign and return the contract offer to ESI within 15 days to enroll in the Tricare pharmacy network for 2023. Those that fail to do so will not be included in the 2023 network, ESI says, but will be given an opportunity to enroll in the network for 2024. If you have received this notification from ESI, please carefully note the sent date to determine your deadline for responding. Failure to sign and return the offer by that deadline means you will not be in the 2023 Tricare network.

The faxed notification specifies the rates of reimbursement for both generic and brand drugs for 2023. Please be sure to review these figures carefully to ascertain whether you wish to participate in the network for 2023, as the terms of reimbursement are different from ESI's past Tricare contracts.

The contract offer we have seen specifies that all claims will be reimbursed at flat rates rather than "effective rates" or averages across multiple drugs. In other words, every generic script covered under the contract would be reimbursed at the same flat (WAC - xx% + $x.xx) rate. All brand drugs would be reimbursed at a specified flat rate as well.

Some of our members report that the proposed ESI reimbursements rates are oppressively low. You should carefully evaluate the offer and make your own conclusion.
Evaluating the ESI Offer
RxCompass -- our powerful data metrics platform -- has some very insightful reports that you can use to help evaluate the reimbursement terms under ESI's 2023 Tricare contract:

Patients by Plan Report
  • This report provides a list of patients with Rx claim activity 
  • Location: Transactional Reports > Patient
  • Recommended report parameters:
  • Use a timeframe of year to date
  • Select the desired BIN/PCN/Group combination(s) (3 separate parameters)
  • Click ‘View Report’
  • Both patient and Rx volume are displayed once the report loads
  • Click the + to the left of the pharmacy name to drill down for individual patient detail
  • Click the blue hyperlink for further detail
  • Click the ‘Back’ hyperlink to return to the parent report, NOT the back button on your browser

Reimbursement Rate Report
  • This report summarizes plan performance 
  • Location: Transactional Reports > Dispensing
  • Recommended report parameters:
  • Use a timeframe of year to date
  • Select the specific BIN/PCN/Group number
  • Date Type: Fill Date
  • Financial Implication: Financially Relevant
  • Formulation Type: Brand, then Generic
  • Run the report twice to see brand and generic performance separately
  • Select both to see aggregate performance
  • Click ‘View Report’
  • Once the report loads, use the search field above the column headings to search for specific BINs
  • Evaluate plan performance with metrics shown and note the volume of distinct patients
  • Click the blue hyperlinks for more detail; click the ‘Back’ hyperlink to return to the parent report, NOT the back button on your browser
  • Reminder: Transactional reports provide point of sale insight only (i.e., pre-rebate).

Known Tricare Plan Identifiers:
  • BIN: 003858
  • PCNs: A4, SC
  • Note: Per ESI, use SC when secondary to Medicare D only.
  • Group: DODA or TRRX