Feb. 12, 2020 
 
      
Update on ESI Contract Addendum
As 20-Day Response Deadline Nears, ESI Not Providing Answers
As previously reported, we have learned that Express Scripts recently sent a new contract addendum to pharmacies that provides a very short deadline of 20 days to decline participation, or your pharmacy will automatically be enrolled in the network(s). There appear to be four separate restricted networks offered named EN 30, EN 20, EN 15 and HP (High Performance).  
 
Last week, American Pharmacies suggested that those pharmacies invited to one or more of these networks pose the following questions to ESI:
  1. Which BIN/PCN/Group corresponds to the network(s) covered by the contract addendum?
  2. Which plans participate in the network(s) covered by the contract addendum?
  3. Approximately how many of my pharmacy patients would participate in the network(s) covered by the addendum?  
  4. If ESI is offering participation in more than one network but you want to participate in only one, ask ESI whether you can accept participation in only some of the networks offered.
  5. Ask ESI to provide plan information/current utilization/ number of lives for each schedule offered, so you can make an informed decision for your pharmacy.
  6. Ask ESI to provide the expected generic run rate/MAC rates for each schedule network offered.
  7. Confirm if any Prime Therapeutics plans will use the offered network(s) and, if so, which Prime plans/ ESI Networks. 
However, based on reports we have received, we are hearing that ESI declined to answer any of these questions, instead stating only: "Since the proposed Amendment simply adds new network options that a Sponsor may select, the information you requested below is not available." This non-answer provides nothing that would help a pharmacy decide whether to join the network(s).  At least two of these networks -- HP and EN30 -- have been in place for years. Essentially then, ESI could provide the requested information but is simply choosing not to do so. We suggest that that any pharmacy interested in evaluating the network(s) remind ESI Contracting that the HP and EN30 networks have been in existence for years and to please provide answers to each of the foregoing questions with respect to these two networks, at a minimum. 
 
If you decide to decline participation in the offered networks, you will still be able to participate in other ESI networks not covered by this addendum. To decline, follow the instructions stated in the addendum and keep for your records a copy of your email declining participation by the stated deadline. We suggest you add the following sentence in your notice: "Furthermore, without ESI identifying which BIN/PCN/Group and plan(s) correspond to the network(s) covered by the contract addendum, I will not know whether a patient participates in any of these networks. Therefore, ESI may not imply my agreement to participate in any of these networks based on the processing of any claim by a patient that may fall under one of the four networks." 
 
Feel free to contact Rick Goebel (APRx Managed Care Consultant) at rgoebel@aprx.org or APRx General Counsel Miguel Rodriguez at mrodriguez@aprx.org with any questions or issues that arise.  
 

Your APRx Board

Alton Kanak, R.Ph.
Chairman
 
Joe Ochoa, R.Ph.  
Vice Chairman
 
Steve Hoffart, Pharm.D.
Secretary/Treasurer
 
Lynn Everett, R.Ph.     
Mike Muecke, R.Ph.
Vance Oglesbee, R.Ph.
Bruce Rogers, R.Ph.