Pharmacy Provider Manual - Express Scripts

1 2019 Express Scripts Canada. All Rights Reserved. @ExpressRxCanada Express Scripts Canada Express Scripts Canada Pharmacy Provider Manual APPLICABLE TO ALL PROVINCES AND TERRITORIES (EXCLUDING QU BEC) December 2019 Version 2019 Express Scripts Canada. All Rights Reserved. 2 @ExpressRxCanada Express Scripts Canada Express Scripts Canada Any comments or requests for information may be transmitted to: Express Scripts Canada Attention: Provider Relations 10th Floor 5770 Hurontario Street Mississauga, ON L5R 3G5 Express Scripts Canada reserves the right to update this Manual and content referenced in this Manual .

2 Data used in examples are fictitious unless otherwise noted. In the event that there are discrepancies between the English and the French version, the English version will prevail. 2009 2019 Express Scripts Canada. All Rights Reserved. Express Scripts Canada is a registered business name of ESI Canada, an Ontario partnership. All reproduction, adaptation or translation is prohibited without prior written authorization, except for cases stipulated by the Copyright Act. Registered or non-registered trademarks and registered product names belong to their respective owners. 2019 Express Scripts Canada.

3 All Rights Reserved. 3 @ExpressRxCanada Express Scripts Canada Express Scripts Canada DOCUMENT REVISION HISTORY Version Date last revised Publication date Details December 2010 December 2010 Revision November 2012 November 2012 Revision April 2016 April 2016 Revision February 2019 April 2019 Revision June 2019 July 2019 Revision December 2019 December 2019 Revision Note: The publication date takes precedence over the date last revised. 2019 Express Scripts Canada. All Rights Reserved. 4 @ExpressRxCanada Express Scripts Canada Express Scripts Canada Table of Contents 1.

4 DEFINED TERMS .. 6 2. INTRODUCTION .. 9 Purpose .. 9 Terms .. 9 Exemptions .. 9 Role of Express Scripts Canada .. 10 Express Scripts Canada Services .. 10 Express Scripts Canada Clients .. 11 3. Pharmacy Provider AGREEMENT .. 12 Pharmacy Provider Agreement .. 12 Liability Insurance and Indemnity .. 12 Pricing Same Level Playing Field .. 13 4. AUDIT AND REVIEW 13 Audit .. 13 Audit Response .. 14 Provider Responsibility .. 14 Review .. 15 5. ADJUDICATION SYSTEM OVERVIEW .. 16 Real-time Processing .. 16 Adjudication System Functionality .. 16 Variations in Pharmacy Practice Management Systems (PPMS).

5 16 6. ENROLMENT AND MODIFICATION TO Pharmacy Provider INFORMATION .. 16 7. CLAIM REIMBURSEMENT PROCESS .. 17 Pharmacy Provider Reimbursement .. 17 Net Reimbursement .. 17 8. CLAIM SUBMISSION PROCESS .. 18 Claim Submission Requirements -- General .. 18 Direct Electronic Claim Submissions .. 19 Deferred Claim Submissions .. 20 Manual Claim Submissions Claims Exceeding $9, .. 20 compound Claim Submissions .. 21 Methadone and Suboxone Claim Submissions .. 22 Medical Cannabis Claim Submissions .. 22 9. CLAIM REVERSALS .. 22 Electronic Claim Reversals .. 22 Deferred Claim Reversals.

6 23 Manual Claim Reversals .. 23 2019 Express Scripts Canada. All Rights Reserved. 5 @ExpressRxCanada Express Scripts Canada Express Scripts Canada 10. DISPENSING QUANTITIES AND UNITS OF MEASURE .. 23 Extended Supply -- Vacation Supply .. 23 Compliance Packaging .. 23 Units of Measure -- Pack Size Project .. 24 11. PRESCRIPTION SAVINGS CARDS .. 24 12. COORDINATION OF BENEFITS .. 24 Provincial Coordination of Benefits .. 25 Private Coordination of Benefits .. 25 13. PROGRAMS .. 26 Provincial Integration Program .. 26 Drug Utilization Review .. 27 Step Therapy Program.

7 29 Opioid Management Program .. 30 14. OTHER FUNCTIONALITIES .. 31 Maximum Allowable Cost .. 31 Substituting 31 15. PRIOR AUTHORIZATIONS AND LIMITATIONS .. 32 Prior Authorizations .. 32 Coverage Limitations .. 33 16. CONTACT US .. 34 Express Scripts Canada Website for Health Care Providers .. 34 Provider Contact Centre .. 34 17. OTHER CONTACTS .. 35 Canadian Pharmacists 35 Software Certification/Network Communications .. 35 18. APPENDICES .. 36 Appendix A Sample Modification to Pharmacy Provider Information Form .. 36 Appendix B Common CPhA Response Codes .. 37 Appendix C Sample Remittance Advice.

8 39 Appendix D Reimbursement Guidelines for Compounded Drugs in BC, MB, ON and SK .. 40 2019 Express Scripts Canada. All Rights Reserved. 6 @ExpressRxCanada Express Scripts Canada Express Scripts Canada 1. DEFINED TERMS The glossary below lists terms and definitions that may be relevant as background information when reading the Pharmacy Provider Manual . Term Definition Benefit plan A health care plan through which Pharmacy prescription benefits are available to eligible Members. A benefit plan is also referred to as a drug benefit plan or a plan. Cannabis Provider A cannabis Provider is a Provider bound by the terms and conditions detailed in the cannabis Provider agreement.

9 Carrier Insurance company underwriting or administering benefits for the benefit plan. Claim Submission for which the Pharmacy Provider or member applies for reimbursement for all or a portion of the cost of a covered medication upon dispensing. Client Insurance carrier, third-party administrator (TPA), employer or other organization with primary financial responsibility for the reimbursement of covered medication dispensed by the Pharmacy Provider , according to the benefit plan design or savings card specifications. ESC clients include, but are not limited, to carriers. Co-ordination of benefits (CoB) Coordination of benefits between two benefit plans, whether they are private, public or a mix of public and private coverage.

10 Copayment Portion of the total charge for each individual prescription that a member is required to pay to a Pharmacy Provider in accordance with that member s benefit plan. For example, a $3 copayment per prescription means that $3 is a member s out-of-pocket cost on each prescription. Covered medication(s) Prescription drugs, supplies and other items prescribed by an authorized, licensed practitioner and covered by a benefit plan. CPhA Canadian Pharmacists Association. CPhA Pharmacy claim standard (CPhACS) Standard rules of electronic claim transmission published and updated by the CPhA. A copy may be obtained directly from the following address Canadian Pharmacists Association 1785 Alta Vista Drive Ottawa, ON K1G 3Y6 Phone: 613 523-7877 Fax: 613 523-0445 2019 Express Scripts Canada.