May 22, 2020 

Important Info On ESI Med   D Contract
Amendment Has Unfavorable Terms & Short Deadline for Decision

Express Scripts Inc. (ESI) will begin managing Prime Therapeutics' Medicare Part D networks effective January 1, 2021. Some pharmacies recently began receiving notices from ESI with a contract addendum for an ESI "Prime Medicare Part D Performance Amendment" that creates a network for Prime Therapeutics' Part D members. This amendment automatically takes effect unless your pharmacy declines participation by the stated deadline. The deadline is 20 calendar days after receipt of the notice, so pharmacies that received the notice must quickly evaluate the addendum and act. 
After reviewing the addendum, we want to highlight the following key points:
  • Whether you accept or reject the addendum, the stated brand reimbursement rate is a sharp reduction versus the current Prime Therapeutics Part D reimbursement rate and comes with no dispensing fee.

  • Accepting the addendum:
    • would permit you to become a preferred pharmacy in the network but it would not guarantee preferred provider status;  
    • would make your pharmacy subject to a per-claim DIR fee even if you are not selected to be a preferred provider (a separate Part D DIR calculation would be done for those that do not accept the amendment based on the current ESI Part D contract); 
    • would require you to pay a $0.50 per claim fee; and
    • would permit some pharmacies to collect a bonus, in an undetermined amount, based on performance.

  • Declining the addendum:     
    • would still allow you to serve members in ESI's Part D network. However, if the network sponsor establishes tiered co-payments, Part D beneficiaries will pay a higher co-pay at your pharmacy than at a preferred pharmacy.
Given the short deadline, you should review the addendum quickly if you received it and, if you do not want to participate, let ESI know you are declining the 2021 Prime Medicare Part D Performance Amendment.