ATT017_XP005_PharmacyNetworkDispensing.pdf

Pharm-XP-005

Pharmacy Network and Dispensing Rules External Standard Operating Procedures

Original Publication June 2022 Revised March 2025

Introduction The World Trade Center (WTC) Health Program contracts with a Pharmacy Benefits Manager (PBM), Express Scripts (ES), to provide pharmacy services. As part of this service, the Program utilizes the ES pharmacy network which has specific requirements based on cost savings for retail, home delivery, and specialty pharmacies. Part of the requirements limit the type of medication and the days’ supply that can be billed.

This guide describes the Program’s policy and processes pertaining to retail, home delivery, and specialty pharmacy use for survivors and responders. It also describes common pharmacy rejection messaging and the appropriate actions to take.

Process and Procedure

Retail Pharmacies

Responders (Retail)

1. Network: Voluntary Smart90 Walgreens/Duane Reade maintenance retail program

1.2 Days’ Supply:

1.2.1 Walgreens/Duane Reade: Up to a 90-day supply of non-specialty maintenance medications at Walgreens/Duane Reade retail pharmacies

1.2.2 Other In-network Pharmacies: Up to a 30-day supply of non-specialty maintenance medications at any other retail pharmacy in the network.1 Survivors (Retail)

1. Network: Voluntary Smart90 Anywhere maintenance at retail program

1.1 Days’ Supply: Up to a 90-day supply of non-specialty maintenance medication at any in-network retail pharmacy after submitting the claim through their primary insurance.

1.2 Coordination of Benefits (COB): Survivors must use their primary insurance first. Primary insurance may specify days’ supply requirements, pharmacy network, and formulary requirements and/or clinical rules that must first be met prior to the claim being submitted for secondary coverage to the WTC Health Program through ES (See Pharm-XP-003).

Home Delivery Pharmacies

The Program does not require members to use home delivery; participation is voluntary.

1. Candidates for Express Scripts Home Delivery:

1.1 Certified members (not on diagnostic formulary).

1.1.1 Members taking non-specialty maintenance medications long-term; and

1 Members may search for in network pharmacies in the Member Portal or mobile app. They may also call ES Member Services to find a pharmacy. CCEs/NPN can search for in network pharmacies in CSP.

1.1.2 Survivors’ primary coverage must be with another ES Home Delivery eligible plan. Members with other health coverage outside of Express Scripts can use a different Home Delivery Service as outlined in the Survivors (Home Delivery) section below.

A member may begin using the ES Home Delivery Pharmacy by following one of these easy options:

1. Option 1: The simplest way is for a member to request their doctor send a new electronic prescription for up to a 90-day supply, plus refills for up to one year (if appropriate) to ES Home Delivery Pharmacy.

2. Option 2: A member may download the ES mobile app. After logging in, the member taps on the “Prescriptions” tile to see which of their current prescriptions are eligible to be filled. The member simply chooses the ones they’d like to transfer and tap the “Order Now” button to add to their shopping cart. When they’ve finished adding prescriptions, the member confirms their doctor’s information, and delivery address before tapping the “Place Order” button.

3. Option 3: A member may visit express-scripts.com/Rx. After logging in, then select “Transfer your retail prescriptions” to get started. If no refills are remaining, or if there are not 90 days remaining, ES will request a new 90-day prescription from your prescriber.

ES Home Delivery offers a voluntary automatic refill service for members. Information about this program can be found below:

1. Express Scripts Home Delivery automatic refill program eligible medications include many maintenance medications, generic and brand equivalents.

2. Automatic refill choice is displayed to members through order processing and can be chosen during order checkout.

3. Medication eligibility for use in automatic refill is reviewed and reevaluated at least once per year using the most up-to-date information to ensure appropriateness for automatic refill. This may result in the addition of new medications to the eligibility list or removal of medications that were previously eligible. While many factors are considered, the primary goal is to ensure that patients consistently receive appropriate supplies of medication at appropriate intervals.

Responders (Home Delivery)

1. Network: ES Home Delivery Pharmacy is the only in-network pharmacy.

1.1 Days’ Supply: Up to a 90 days’ supply of maintenance medications.

2.1 General Process: All maintenance medications can be sent directly to ES Home

Delivery Pharmacy (e-prescribe, fax, mail, phone).

Survivors (Home Delivery)

1. Network: The home delivery pharmacy that is in-network for both the survivor’s primary insurance and ES to allow for coordination of benefits. For survivors, the ES network includes CVS/Caremark and Optum in addition to ES Home Delivery.

1.1 Days’ Supply: Up to a 90 days’ supply of non-specialty maintenance medications

1.2 COB: A survivor must first use their primary insurance. COB requirements must be met for all Survivor Prescriptions (See Pharm-XP-003).

https://express-scripts.com/Rx

1.2.1 The member’s primary insurance may have specific requirements for which home delivery pharmacy the member can use (e.g., CVS may require CVS/Caremark for home delivery). Survivors must use the home delivery that is in network with their primary insurance and ES to get prescriptions through the WTC Health Program. If ES, Optum, and CVS/Caremark are not in network with the survivor’s primary insurance, they must use retail.

1.2.2 Please Note: Survivor members can only use ES Home Delivery if their primary insurance is also ES. ES Home Delivery cannot bill other insurance carriers.

1.3 General Process:

1.3.1 The member will have to determine what home delivery pharmacies are in network with their primary insurance.

1.3.1.1 If the member can find a home delivery pharmacy that is in network with both the primary insurance and WTC Health Program network (ES, CVS/Caremark, Optum), the member must register with that home delivery pharmacy and provide their primary insurance card along with their WTC Health Program Prescription ID Card.

1.3.1.2 If the primary insurance does not have an in-network pharmacy that is also in network with ES, the member will have to fill prescriptions at retail.

Specialty Pharmacies

Specialty drugs are high-cost prescription medications used to treat complex, chronic conditions like cancer and rheumatoid arthritis. Specialty drugs often require special handling (special dosing, administration, and storage). They may require frequent dosing adjustments and intensive clinical monitoring to decrease the potential for drug toxicity and increase the probability for beneficial treatment outcomes. These medications often require intensive patient training and compliance assistance to facilitate therapeutic goals.

Examples of specialty drugs used in the WTC Health Program are cancer medications, Humira, Xolair, etc. ES has provided the Program with a list of specialty medications that would be applicable to this section.2 That list can be found on the PBM Online Document Repository.

Therapeutic Resource Centers (Accredo) Accredo is the Express Scripts Specialty Pharmacy. Accredo offers specialized services through the Therapeutic Resource Centers (TRCs).

Pharmacists with specialized training in complex and chronic conditions provide the TRC services. These TRCs offer personalized clinical care to ensure patients get the information and counseling they need to adhere to their therapies and achieve healthier outcomes. The TRCs are a cornerstone of clinical specialization. Conditions served by TRCs include, but are not limited to, cancer and autoimmune conditions.

1. Specialized pharmacists are available for members Monday-Friday 8AM-11PM EST, and Saturday 8AM-5PM EST.

2 Note that the specialty list is updated by ES.

2. Use of Accredo Specialty Pharmacy is safe and convenient.

3. Prescriptions dispensed by Accredo arrive promptly at members’ homes by USPS, UPS, and/or FedEx.

4. Medications are almost always in stock whereas many times retail pharmacies may have to special order.

5. Members experience fewer trips to the pharmacy and do not have to wait in pharmacy lines.

6. Members experience adherence improvement due to refill reminders by Accredo.

Responders (Specialty)

1. Network: Exclusive use of Accredo Specialty Pharmacy for drugs that are listed on the Accredo Specialty Pharmacy List (available in the PBM Online Document Repository).

1.1 Days’ supply: Up to a 30-day supply of specialty medication

2.1 General Process:

2.1.1 Determine if the medication is on the Accredo Specialty List.

2.1.2 Physicians should send the member’s specialty prescription (via electronic prescription, mail, fax) directly to Accredo Specialty Pharmacy.3,4

2.1.3 If a physician sends an applicable prescription to a pharmacy other than Accredo, the prescription will reject at the pharmacy as out of network (Reject 4W). The prescriber will need to send a prescription to Accredo.

2.1.3.1 If the member had already previously filled through Accredo, Accredo will call the prescriber for a new prescription if a renewal or refill is needed.

2.1.4 Upon receiving the prescription and applying all plan design, clinical rules, and protocols, Accredo will contact the member to schedule delivery. Medication will not be shipped until Accredo has first coordinated with the member to confirm delivery location and that someone will be available to accept the delivery.

2.1.5 Limited Distribution Drugs (LDD): Some specialty medications are limited distribution meaning they are restricted to specific pharmacies for dispensing. Many LDD drugs are available at Accredo. For those that are not available at Accredo, they will not be stocked, and the member/provider should contact the manufacturer to identify the pharmacies available for distribution, send the prescription there, and the pharmacy can bill the Program. A list of LDD is regularly updated by ES on the PBM Online Document Repository.

Survivors (Specialty)

1. Network: Any in-network retail or specialty pharmacy.

1.1 Days’ Supply: Up to a 30-day supply of specialty medication.

1.2 COB: A survivor must first use their primary insurance. COB requirements must be met for all Survivor Prescriptions (See Pharm-XP-003).

3 If provider submits a specialty medication to ES Home Delivery, they will automatically send it to Accredo to process. The provider and member do not have to take any action.

4 Members using Accredo do not need to be enrolled.

1.2.1 The member’s primary insurance may have specific requirements for which specialty pharmacy the member can use (e.g., CVS may require CVS/Caremark for specialty). Survivors must use the specialty pharmacy that is in network with their primary insurance and ES to get prescriptions through the WTC Health Program.

1.2.2 Please Note: Accredo can bill other primary insurances if they are in network (in network meaning the primary plan allows their members to use Accredo Specialty Pharmacy).

1.3 General Process:

1.3.1 The member will have to determine what specialty pharmacies are in network with their primary insurance.

1.3.1.1 If the primary insurance does not have an in-network specialty pharmacy that is also in-network with ES, the member will have to fill their prescriptions at retail.

1.3.1.2 If the primary insurance requires exclusive use of a specialty pharmacy that is not in the ES network, the member will have to pay out of pocket and submit a paper claim to ES for reimbursement. The CCE/NPN should also notify the Program if they are aware of this issue, so that ES can try to contract with the specialty pharmacy.

1.3.2 If the member finds a specialty pharmacy that is in network with both the primary insurance and WTC Health Program network, the member must make sure they are registered with that specialty pharmacy5 and provide their primary insurance card along with their WTC Health Program Prescription ID Card.

1.3.3 The member should inform the pharmacy of the COB requirements (See Pharm-XP-003).

1.3.4 Physicians should then send the member’s prescription to the pharmacy (via electronic prescription, mail, fax).

1.3.5 Once the prescription is ready (applying all plan design, clinical rules, and protocols) the pharmacy may contact the member to schedule delivery or to pick up the medication, depending on that pharmacy’s process.

Dispensing Options

Initial Health Evaluation or Annual Monitoring Exam

Treatment Visit

Treatment Visit

– Diagnostic

Behavioral Health

Retail Network

30-day supply for diagnostic purposes

Up to a 90-day supply

30-day supply Up to 90-day supply

5 WTC Health Program members using Accredo do not need to register.

Home Delivery Network

Not recommended

Up to a 90-day supply

Not recommended

Up to 90-day supply

Specialty Not applicable Up to 30-day supply*∞

Not applicable Not applicable

*Some specialty medications have dosing intervals that allow for billing of a day supply greater than 30

∞Responder members must use Accredo Specialty Pharmacy unless the drug is not available through Accredo. See the Limited Distribution Drug List (LDD) available in the Document Repository on the Evernorth Control Center for more information.

Quality Controls The Program and Express Scripts will monitor the above processes and utilization at their discretion including:

1. General utilization of Accredo, Home Delivery, and Retail

2. Utilization of specialty medications – Retail vs Accredo

3. Utilization of maintenance medications – Walgreens/Duane Reade, Home Delivery

4. Turnaround time for processing and delivering of medications

5. Therapeutic Resource Center statistics

6. Override decisions for medications

7. Spending and savings key performance indicators (KPIs)

Acronyms & Definitions Term Definition

CCE Clinical Centers of Excellence

COB Coordination of benefits (COB) applies to members who are covered by more than one prescription plan. COB mainly affects survivors as they are required to use their primary prescription plan before using WTC Health Program benefits.

CSP Customer Service Portal

ES Express Scripts, Incorporated (Express Scripts)

Home Delivery Home delivery can also be referred to as mail order. Home delivery is a means of dispensing medications from the pharmacy directly to members’ homes via delivery (USPS, FedEx, UPS).

In-Network Pharmacy

An in-network pharmacy is a pharmacy that has an agreement with ES to dispense prescription drugs to members.

KPI Key Performance Indicator

Maintenance Medication

Maintenance medications are those commonly prescribed for long-term, daily use to treat chronic conditions.

NPN Nationwide Provider Network

PBM Pharmacy Benefits Manager

PBT Pharmacy Benefits Team

Specialty Medications

Specialty medications are prescription drugs classified as high cost, high complexity, and/or high touch. Some specialty medications require special storage such as refrigeration or special administration such as injection or infusion. Specialty medications are often prescribed to treat complex conditions that require frequent follow ups with prescribers, pharmacists, and/or nurses.

Revision History March 2025 Removed previous reject codes table as it now exists as its own separate Reference Guide.

Also added in language about days’ supply and quantity limits, reflected Express Scripts branding change, and added a dispensing options table reference for the various

October 2023 Removed transition language from new PBM implementation, added common pharmacy rejection messaging and the appropriate actions to take, updated Accredo Specialty Pharmacy hours for members. Updated title and made minor technical changes and clarifications that don’t affect the content of the SOP.

June 2022 Initial publication.

Dispensing Options