Express Scripts, Inc. provides a range of pharmacy benefit management services in North America. It offers retail drug card programs, home delivery pharmacy services, Specialty services, drug formulary management programs and other clinical management programs.
Segments
The company operates in two segments: Pharmacy Benefit Management Services (PBM) and Specialty and Ancillary Services (SAAS). The company's PBM segment includes domestic and Canadian PBM operations. The company's SAAS segment includes the Specialty operations of CuraScript, and its SDS and PMG service lines.
Products and Services
Pharmacy Benefit Management Services
The company offers its PBM services to its clients in the United States and Canada. Its PBM services include: retail network pharmacy management, home delivery pharmacy services, benefit design consultation, drug utilization review, formulary management programs, disease management, and compliance and therapy management programs for its clients.
Retail Pharmacy Network Administration: The company contracts with retail pharmacies to provide prescription drugs to members of the pharmacy benefit plans it manages. It manages nationwide networks in the United States that are responsive to client preferences related to cost containment and convenience of access for members. It also manages networks of pharmacies. The company manages one nationwide network in Canada.
Patient Services: As of December 31, 2006, the company operated three home delivery pharmacies located in Maryland Heights, Missouri; Bensalem, Pennsylvania; and Tempe, Arizona. In addition to front-end order processing that occurs at the company's home delivery pharmacies it also operates three front-end order processing facilities in Troy, New York; Harrisburg, Pennsylvania; and Albuquerque, New Mexico. In addition, the company operated seven contact centers located in Albuquerque, New Mexico; Bloomington, Minnesota; Farmington Hills, Michigan; Harrisburg, Pennsylvania; St. Marys, Georgia; Tempe, Arizona; and Pueblo, Colorado.
Patient Care Contact Centers: The company contracts with health plans, the ultimate recipients of many of its services are the members of these health plans.
Benefit Plan Design and Consultation: The Company offers consultation and financial modeling to assist its clients in selecting benefit plan designs that meet their needs for member satisfaction and cost control. The company’s benefit design options to its clients include: financial incentives and reimbursement limitations on the drugs covered by the plan, including drug formularies, tiered co-payments, deductibles or annual benefit maximums; generic drug utilization incentives; incentives or requirements to use only certain network pharmacies or to order certain maintenance drugs (i.e. therapies for diabetes, high blood pressure, etc.) only for home delivery; reimbursement limitations on the amount of a drug which can be obtained in a specific period; and by implementing utilization management programs such as Step Therapy and Prior Authorization, that focus the use of medications according to clinically developed algorithms.
Formulary Development, Compliance and Therapy Management: The company administers a number of different formularies for its clients that identify drugs, the use of which is encouraged through various benefit design features. The company also provides formulary compliance services to its clients. It also offers clinical intervention programs to assist and manage patient quality of life, client drug trend, and physician communication/education. These programs encompass comprehensive point of service and retrospective drug utilization review, physician profiling, academic detailing, prior authorization, disease care management, and clinical guideline dissemination to physicians.
Rebate Programs: The company develops, manages and administers rebate programs that allow pharmaceutical manufactures to provide rebates on utilization of their products by members of its clients’ benefit plans.
Information Reporting and Analysis and Disease Management Programs: The company offers disease management and education programs to members in managing clinical outcomes and the total health care costs associated with certain conditions such as asthma, diabetes and cardiovascular disease. These programs are based on the premise that better informed patient and physician behavior can positively influence medical outcomes and reduce overall medical costs.
The company offers a tiered approach to member education and wellness, ranging from information provided through its Internet site, to educational mailings, to its one-on-one registered nurse or pharmacist counseling. The programs include providing patient profiles directly to their physicians, as well as measurements of the clinical, personal and economic outcomes of the programs.
Electronic Claims Processing System: The company's electronic claims processing system enables it to implement intervention programs to assist in managing prescription drug utilization. The system can alert the pharmacist to generic substitution and therapeutic intervention opportunities as well as formulary compliance issues, or administer prior authorization and step-therapy protocol programs at the time a claim is submitted for processing. The company's claims processing system also creates a database of drug utilization information that can be accessed both at the time the prescription is dispensed and also on a retrospective basis to analyze utilization trends and prescribing patterns for more intensive management of the drug benefit.
Consumer Health and Drug Information: The company maintains a public website, www.DrugDigest.org, to helping consumers make informed decisions about using drugs. The information on DrugDigest.org includes: a drug interaction checker, a drug side effect comparison tool, tools to check for less expensive generic and alternative drugs, audible drug name pronunciations, comparisons of different drugs used to treat the same health condition, information on health conditions and their treatments, instructional videos showing administration of specific drug dosage forms, monographs on drugs and dietary supplements, photographs of pills and capsules, and interactive care pathways and health risk assessments.
SAAS Services
The company's SAAS segment includes the Specialty operations of CuraScript, and its SDS and PMG service lines. Through the company’s SAAS segment provides specialty services, including delivery of injectible and infusible drugs to patient homes, physician offices, infusion centers and certain associated patient care services; distribution of pharmaceuticals and medical supplies to providers and clinics; third party logistics services for contracted pharma clients; and bio-pharma services including reimbursement and customized logistics solutions. The SAAS segment also includes distribution of specialty pharmaceuticals requiring special handling or packaging; distribution of pharmaceuticals to low-income patients through manufacturer-sponsored branded and company-sponsored generic patient assistance programs; and distribution of sample units to physicians and verification of practitioner licensure.
Patient Services: Services to patients include coordinated delivery of specialty pharmaceuticals and management of multiple facets of a patient’s treatment which can include personal instruction on the self-administration of a patient’s therapy, clinical support, support with billing and reimbursement issues and a range of educational materials, including online information portals. The company utilizes clinically based CARELogic programs to provide therapy-specific care management of the injectible therapy, including appropriateness, compliance, dosing and cost control.
Payor Services: The company offers health plan providers and their members customized disease-specific treatment programs which cover both pharmacy and medical benefits. In addition to helping payors design a customized plan, the company assists with eligibility review, prior authorization coordination, monitoring and reporting of patient therapy adherence as well as electronic claims processing and billing. The company's monitoring and reporting of patient therapy includes clinical tracking, plan-specific reports, and provider treatment and dispensing patterns. The company is able to provide a clinical and financial picture of plan members with chronic illnesses which measures pharmacy expenses and patients’ treatment progress.
Physician Services: Through its CuraScriptSD business unit, the company provides distribution services primarily to office and clinic-based physicians treating chronic disease patients who regularly order pharmaceuticals.
Biotech Services: The company designs strategies tailored to each product’s needs with a focus on identifying opportunities to educate the marketplace regarding drug effectiveness, proper utilization and payor acceptance.
Other Services: The company also provides a range of centralized supply chain services which can include sampling programs, patient assistance programs, and clinical trial assistance as well as specialized shipping and storage and customized dosing.
The company provides specialty distribution services, consisting of the distribution of, and creation of a database of information for, products requiring special handling or packaging, products targeted to a specific physician or patient population, and products distributed to low-income patients. The company's services include eligibility, fulfillment, inventory, insurance verification/authorization and payment.
Clients
The company's clients include HMOs, health insurers, third-party administrators, employers, union-sponsored benefit plans and government health programs. The company provides Specialty services to customers who also include HMOs, health insurers, third-party administrators, employers, union-sponsored benefit plans, government health programs office-based oncologists, renal dialysis clinics, ambulatory surgery centers, primary care physicians, retina specialists, and others.
Joint Ventures
Aetna Specialty Pharmacy, a joint venture existing between Priority and Aetna, Inc. (Aetna), was 60% owned by Priority and 40% by Aetna. Upon a change in control of Priority, the joint venture agreement provided Aetna with an option to purchase Priority’s 60% ownership share of the joint venture.
Competition
The company's competitors include Caremark, Catalyst RX, Innoviant, Medco, MedImpact, PerformRX, Aetna, Cigna, First Health, Humana, Prime Therapeutics and Wellpoint. Some are owned by retail pharmacies, such as Pharmacare (owned by CVS), RX America (owned by Longs Drug Stores), Rite Aid Health Solutions and Walgreens Health Initiative. The company also competes against specialized providers, such as Argus and SXC Health Solutions.
History
Express Scripts, Inc. was incorporated in 1986.
