greater care. zero waste. proprietary and confidential © 2011 express scripts, inc. all rights...

Greater Care. Zero Waste.

PROPRIETARY AND CONFIDENTIAL © 2011 Express Scripts, Inc. All Rights Reserved.

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County of Los Angeles Pharmacy Program OverviewOctober 2011

DATA_OWNER



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What We’ll Discuss Why Express Scripts for Workers’ Compensation (WC)

Overview of the Pharmacy program

How the program controls cost Capturing First Fill and On Going prescription needs

Formulary and Clinical programs Safety for patient Prevents fraud and abuse

Resources for you and your claims handlers Program support



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Workers’ Compensation Industry Leader

• Nationwide Workers’ Compensation

pharmacy network

• Workers’ Compensation injury-specific formularies

• Aggressive paper bill solution

• Industry-leading technology

• Clinical Advisory Committee to ensure clinical program effectiveness

• Leverage clinical experience to offer improved outcomes and savings

Serve the injured worker while driving to the lowest net costServe the injured worker while driving to the lowest net cost

Express Scripts ensures safety for

your injured workers, while aggressively

reducing waste



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Drive Out the Waste

Ease of administration and process efficiencies further drive savingsEase of administration and process efficiencies further drive savings



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Comprehensive Pharmacy Program

Proven pharmacy solutions delivering safety, savings, and satisfaction

Our solution is a complete package for Workers’ CompensationOur solution is a complete package for Workers’ Compensation

Core ServicesCore Services Trend ProgramsTrend Programs Clinical ProgramsClinical Programs



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How Prescription Gets FilledCORE SERVICES

CORE SERVICES



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Script can be filled before the claim is reported – 14 Day Supply

Eligibility

1- Work Comp Acute Drug List

2- Standard List for Ongoing NeedsFormulary

Management

Assures that non-formulary medications are identified and sent for approval

Prior Authorization

Best practices in each key operation drive safety, savings, and satisfactionBest practices in each key operation drive safety, savings, and satisfaction

Value of First Fill Form



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First Fill Form



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Nationwide Pharmacy Network

Express Scripts’-owned network is contracted directly with pharmacies, specifically for workers’ compensation

More than 57,000 pharmacies nationwide Includes major retail chains in Los Angeles County

Wal-Mart

Target

Express Scripts will recruit additional pharmacies to meet your needs

Contracting standards – urban area within 1 mile – suburban with 5 miles and rural within 15 miles

Express Scripts’ goal: a network pharmacy within one mile of an injured workerExpress Scripts’ goal: a network pharmacy within one mile of an injured worker

Rite Aid Albertsons

CVS Ralph’s Pharmacy



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Core Services

Dedicated Workers’ Compensation resources and capabilities

Formulary Management Account service team Patient care contact centers Home delivery pharmacy Reporting



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Clinical Programs

Concurrent Drug Utilization Review Retrospective Drug Utilization Review Physician Outreach Program Step Therapy ScriptAlert Pharmacist’s Drug Review (PDRx)

Increasing safety and clinical effectiveness



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Clinical Programs

Drug Utilization Review

Concurrent DUR Retrospective DUR

Goal of review Deter fraud and abuse and increase patient safety

Review occurs At point-of-service After script is filled

Corrective actionDispensing pharmacist

alertedPhysicians alerted on

findings

Designed to ensure injured worker safetyDesigned to ensure injured worker safety



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Delivering Savings to Clients

Physician Outreach Program

Goal: Decrease use of brands and increase generics being dispensedGoal: Decrease use of brands and increase generics being dispensed

Delivering Savings to Clients



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Trend Programs

Step Therapy (effective 1/1/12)

Encourages use of generics before more costly brand-name alternativesEncourages use of generics before more costly brand-name alternatives



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Clinical Programs

ScriptAlert Reporting

We identify potentially

high-risk claims

Send Monthly report

Client can take appropriate course of action• Aggressive case management• Independent medical examinations• Physician or peer-to-peer

conversations

Enabling Patient Safety



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Clinical Programs

Pharmacist Drug Review (PDRx)

Submit request with all pertinent medical recordsRequestRequest1ReviewReview2

Licensed pharmacist reviews injured worker’s complete medical file

ReportReport

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Clinical assessment conducted to:• Identify specific drug therapy problems• Offer recommendations• Propose desired clinical outcomes



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Resources



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Contact Center

• Pharmacy assistance, new claims, eligibility updates, medication approvals, etc.• Call 24/7 at 1-800-676-5774 or email [email protected]

Client Support Center (CSC)

• Escalated pharmacy and eligibility requests• Call Monday – Friday 5:30 am-5:30 pm (MST) at 1-877-292-1226 or e-mail

[email protected]

Mail Conversion Center (MCC)

• Assistance with converting injured workers’ scripts to Home Delivery• Call Monday – Friday 7:30 am-5:00 pm (CST) at 1-866-533-6227 or e-mail

[email protected]

Account Management Support

• Assist with program changes and escalations beyond above teams• [email protected] or 800-332-5455 ext. 232203 • [email protected] or 800-332-5455 ext. 433175

Express Scripts Resources



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Drug Informationwww.drugdigest.org

Evidence-based website

Drug information Drug interactions Generic availability Approved

indications (reasons for use)



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Adjuster Tools



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Alignment with County of Los Angeles

Our program is designed to meet your business objectivesOur program is designed to meet your business objectives

SafetySafety

SavingsSavings

SatisfactionSatisfaction



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Express ScriptsWorkers’ Compensation

Your perfect pharmacy solution for injured workers

DATA_OWNERDATA_OWNER

greater care. zero waste. proprietary and confidential © 2011 express scripts, inc. all rights...

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