Express Scripts Response to Novel Coronavirus (COVID-19)

Friday, February 04, 2022
OTC COVID Test Updates

Member Experience:

• Neither a prescription nor prior authorization (PA) is required.
• Each member is eligible for up to eight (8) over-the-counter (OTC) tests per month.
• Point-of-sale (POS) and home delivery coverage available at participating pharmacies.
• When Point-of-sale (POS) coverage is not available, members submit manual claims for reimbursement.

Member Cost:

• Member cost share is $0.00 at participating point-of-sale (POS) and home delivery pharmacies. Members pay applicable shipping costs.
• Reimbursement for manual claims is capped at the lesser of the test cost or $12.00.

Plan Cost:

• Test kits purchased at participating point-of-sale (POS) and home delivery pharmacies adjudicate at usual and customary (U&C) rates.
• Reimbursement for manual claims is capped at the lesser of the test cost or $12.00.
• Standard billing cycle.

Tuesday, January 25, 2022
Latest Guidance About the OTC COVID Test

The Biden administration issued guidance recently requiring private health insurance companies to reimburse and cover members for up to eight (8) over-the-counter (OTC) COVID-19 tests per month.

Client Enrollment Process:

Clients will be automatically enrolled into Express Scripts COVID-19 Test Kit program. If a client wishes to opt out of coverage for COVID-19 test kits, please contact your Account Manager by January 26, 2022.

Confidio Performance Pharmacy Solution (PPS) clients should communicate with their Confidio Account Management Team to indicate if they would like to elect for a per claim versus the install fee.

Member Details:

• A written prescription or prior authorization is not required.
• Each member is eligible for up to eight (8) OTC COVID-19 tests per month.
• In Network: Point-of-sale (POS) and mail order coverage at participating network pharmacies is currently unavailable. Members must submit a claim form and a copy of their receipt for reimbursement.
  • Point-of-sale (POS) claim processing for Confido clients: will receive an email from ESI advising of their go-live date
  • Point-of-sale (POS) claim processing for RxBenefits 360 clients: Target date of January 28, 2022
• Out of Network: Members must submit a claim form and a copy of their receipt for reimbursement.
• RxBenefits direct clients may contact RxBenefits Member Services for assistance filing claims:
  • By phone: 1.800.334-8134
  • By email: customercare@rxbenefits.com
  • Hours: 7:00am – 8:00pm
• Confidio Clients: Contact the Express Scripts customer service number noted on ID cards for assistance filing claims.

Member Cost:

• In Network: $0.00 Point-of-sale (POS) (mail order currently not available)
• Out of Network: Plan reimburses 100% (A Safe Harbor status change may apply a $12 reimbursement cap.)

Plan Cost:

• For OTC kits processed through the pharmacy benefit, Express Scripts will process payment of OTC test kits at market-competitive rates.
• Standard contract terms apply for Point-of-sale (POS) and paper claims processing (Outlined in client contract)
• Standard billing cycle.

Additional Resources

• Member Email Template

Friday, January 14, 2022

Important Information About the New OTC COVID Test Guidance

Client Enrollment Process:

• RxBenefits 360 clients will be automatically enrolled into Express Scripts COVID19 Test Kit program. If a client wishes to opt out of coverage for COVID19 test kits, please contact your RxBenefits Account Manager.
• Confidio Performance Pharmacy Solution (PPS) clients will need to enroll via the Express Scripts COVID19 Test Kit microsite. If a client does not wish to enroll in the solution, no action is required, and coverage will not be automatically updated.

Claim Adjudication Process:

• Effective January 15, 2022, COVID19 test kits will not process at point of sale. Members will pay cash and submit a direct member reimbursement (DMR) claim to Express Scripts for reimbursement.
• Once Express Scripts receives the client’s intent to enroll via the microsite, it will take approximately two weeks for the in-network point-of-sale benefit to be in place.
• Once enrolled, members can go to any pharmacy in their existing network to purchase OTC COVID-19 testing kits at point of sale. Out of network pharmacies will require a DMR claim.
• Express Scripts is actively seeking Safe Harbor requirements and once met will be able to cap cost to $12 per test. Until then the $12 cap will not apply to Express Scripts test kit claims but they are working to manage in-network claims to an average cost of $12 per test.
• Members will be limited to eight (8) tests per rolling 30 days. If a member attempts to fill more than 8 eight tests per 30 days, the subsequent fills will not be covered.
• No prior authorization or attesting to COVID Symptoms required for coverage.
• Members will not require a prescription to obtain test kits.

Additional Information:
Build A Community Of Immunity: Your COVID-19 Resource Center | Express Scripts (express-scripts.com)

Friday, May 14, 2021
COVID-19 Vaccine Update

Effective on or after March 15, 2021, single-dose COVID-19 vaccines, will be approximately $40 for administration. For COVID-19 vaccines requiring multiple doses, the rate will be approximately $40 for each dose in the series. This rate reflects updated information about the costs involved in administering the COVID-19 vaccine for different types of providers and suppliers, and the additional resources necessary to ensure the vaccine is administered safely and appropriately.

ESI announced they would reimburse pharmacies based on the new $40 dose rate only if the pharmacy requests it.

Tuesday, December 8, 2020
Important Information From Express Scripts Regarding Coverage of COVID-19 Vaccines

Ahead of the anticipated approval of COVID-19 vaccines, there’s a lot of information out there to understand. RxBenefits and Express Scripts are here to help our mutual clients prepare for the road ahead as COVID-19 vaccines are expected to be approved soon.

While this situation remains fluid and changing, here is what we know:

• Initially, the government will pay for the cost of the vaccine and allocate the initial supply of vaccines to the states for distribution.
  • States will prioritize distribution to health care workers, front line workers, and other high-risk populations.
  • Clients won’t pay for the drug cost of a COVID-19 vaccine until this government funding expires.

Express Scripts Pharmacy Vaccination program:

• Once approved, COVID-19 vaccines will be added to ESI’s Pharmacy Vaccination program.
• For enrolled clients, the vaccines will be covered under their pharmacy benefit once available from local retail pharmacies. Under the benefit, the following will occur:
  • COVID vaccine claims will process the same as all existing claims, except with a $0 ingredient cost.
  • Clients will cover the standard $20 administration cost for each vaccination, and if applicable, the standard dispensing fee and $2.50 vaccine claim program fee.
  • The COVID vaccine(s) will be added to clients’ preventative drug lists, allowing members to bypass deductibles and pay a $0 copay.
• For non-enrolled clients currently, we will be reaching out in early January 2021 to encourage enrollment.
  • ESI is working on an easy enrollment process in January to ensure clients can cover the vaccines as soon as possible.

This is a rapidly evolving situation, and we know you have concerns. Ensuring the health and safety of our employees, shared clients, and their members is our top priority. Additional information from ESI on COVID-19 vaccines can be found here.

Thursday, November 19, 2020
Express Scripts Removing COVID-19 Anti-stockpiling Limits and Policies Effective December 31, 2020

On Dec. 31, 2020, Express Scripts will be retiring the COVID-19 anti-stockpiling limits and associated policies. These limits were applied temporarily to combat the stockpiling of specific, currently available medications that may be used to manage COVID-19. The policies are intended to protect the supply of specific, currently available medications that may be used off-label to manage COVID-19. Current data shows that the usage and supply of these medications has returned to baseline.

The limits include the following medications:

• Chloroquine
• Plaquenil
• Kaletra
• Zithromax
• Albuterol/levalbuterol

The policies associated with these limits are:

• Coronavirus Infection Drugs – Kaletra, Plaquenil, Chloroquine – Per Days
  • Coronavirus Infection Drugs – Short Acting Beta-Agonists – Per Days
  • Coronavirus Infection Drugs – Azithromycin – Per Days

As noted back in March, as a part of this COVID-19 related strategy, this change will be automatically updated on behalf of RxBenefits clients, and no action is required by you.

Express Scripts is committed to closely monitoring the marketplace as the COVID-19 epidemic continues. If market dynamics change, they will revisit the need for quantity limits.

Thursday, June 4, 2020
Express Scripts COVID-19 Policy Update: Early Refill Limits to be Reinstated on June 19, 2020

In response to COVID-19, early refill restrictions were temporarily waived for all clients, helping ensure members had access to medications while sheltering in place to avoid the spread of COVID-19. With state governments beginning to ease guidelines and focusing on reopening the economy, plan member access to medical services and local pharmacies will increase. As this continues, some of the exceptions implemented due to the pandemic will not be needed.

Effective June 19, 2020, Express Scripts (ESI) will no longer waive early refill limits on 30-day prescriptions for maintenance medications. At that time, claims for maintenance medications will process in accordance with your standard refill thresholds, and the non-emergency refill threshold limits will again apply.

Tuesday, April 14, 2020
ESI Making Formulary Changes for Albuterol Inhalers 

Due to limited availability of Ventolin® HFA inhalers, effective April 14, 2020, new prescriptions for Ventolin® will be automatically converted to ProAir® (or its generic) for clients supporting both products on formulary. The goal of the Express Scripts Pharmacy is to maintain access to therapy for patients currently established on Ventolin®, while also ensuring new patients receive a sustainable therapy. 

Wednesday, April 1, 2020
ESI Announces New COVID-19 Anti-Stockpiling Efforts

In the wake of the COVID-19 pandemic, Express Scripts has updated its recommendations in an effort to protect medication supplies for patients with clinical necessity and applied new utilization limits to curb unnecessary stockpiling.

These new COVID-19 Anti-Stockpiling policies and quantity limits are designed to combat the stockpiling of specific, currently available medications that may be used to manage COVID-19 thereby protecting the supplies of these therapies. Clients who are enrolled in an Advanced Utilization Management package are being auto-updated with these new limits for no additional fee. These limits are not overly restrictive and are intended for temporary, limited-time use to protect the availability of the following drugs:

1. Chloroquine
2. Plaquenil
3. Kaletra
4. Zithromax
5. Albuterol/levalbuterol

Note, these are therapies intended for acute, inpatient treatment for COVID-19. There is no current approval or clinical evidence for using these therapies for prevention or treatment of outpatient, mild COVID-19 cases.

This is not a custom list, so there is no need or ability to make changes. If a client wants to opt-out of these quantity limits, they may inform their account team. Express Scripts may retire these COVID-19 Anti-Stockpiling quantity limits in the future depending on marketplace developments.

To further support anti-stockpiling practices, Concurrent Drug Utilization Review alerts have been added to remind pharmacists to check the diagnosis and quantity for COVID-19 therapies. This helps drive consistency at the pharmacy, so pharmacists can clearly communicate with a member.

Tuesday, March 24, 2020
ESI Change in Retail Shipping Options

Only pharmacies credentialed as mail order in the Express Scripts pharmacy network are contractually permitted to mail prescriptions. However, due to the COVID-19 pandemic, Express Scripts is granting CVS and Walgreens (via their Walgreens Express™ delivery program) a limited out-of-network delivery exception and will permit them to provide free home delivery of prescriptions to Express Scripts’ members in a manner that would otherwise be prohibited. There are no day-supply limits or drug category limits for this service beyond what is allowed by law. This agreement is solely due to the COVID-19 pandemic and will be in place for 30 days, upon which time it will be revisited by Express Scripts to determine if it is still necessary. The exception went into place for CVS the week of March 16 and for Walgreens the week of March 23.

All CVS and Walgreens retail locations have been notified.

ESI will continue to assess the situation and will provide updates as additional information is known.

Members can also have peace of mind with their prescription medications by using the Express Scripts Pharmacy, which offers free home delivery of up to 90-day supplies of prescription maintenance medications. Pharmacists are available 24/7 to answer questions, offer counseling and support, and assist with prescription orders. Members are encouraged to refill their medications responsibly.

Wednesday, March 18, 2020
RxBenefits Clients with ESI Gain Access to Early Refills Effective 03/20/2020

RxBenefits has taken steps to protect member access to medication. Effective 03/20/2020, all RxBenefits clients with Express Scripts will be able to access up to 2 early refill options on prescription medications. Currently, clients have standard refill policies in place, which allow you to refill or renew a prescription medication when 25%-35% of your current prescription is remaining. The new early refill options would waive early refill limits for medications at any pharmacy. We continue to encourage members to carefully evaluate their options to avoid supply shortages or concerns. Schedule II controlled substance medications will still require a new prescription for additional fills.

Pharmacies will be receiving directions from Express Scripts prior to the 03/20/2020 effective date on how to process these early refill prescriptions. If you believe that your medication should be eligible for an override, and it was not applied, advise the pharmacist to contact the ESI Helpdesk for guidance or please contact your RxBenefits Member Services team at RxHelp@RxBenefits.com or call 800.334.8134.