The Express Scripts Special Investigations Unit (SIU) has previously sent reminders to ensure that the co-payment collection guidelines are being followed. Express Scripts has continued to identify multiple Network Providers that are missing co-payment collection documentation.
Section 2.3 of the Provider Manual specifically outlines Express Scripts’ policy on collection of co-payments. Co-payments are a critical benefit design tool that can sensitize Members to the cost of their medications and encourage Members to seek less expensive medications that are as clinically effective. Network Provider agrees that it shall collect the full Co-payment from Members, and that the Co-payment is not changed or waived unless required by law.
Section 2.4 of the Provider Manual specifically outlines Proof of Service Requirements. These requirements include point of sale “POS” receipts indicating price paid by member. Documentation that meets this requirement include:
- Credit card receipt
- POS receipt indicating cash payment
- Copy of cancelled check
If Express Scripts learns that a Network Provider has failed to collect Co-payments from one or more Members, Network Provider can be subject to termination. Express Scripts may discover these facts through audit, investigation, member statements, or other sources.
If you learn of any pharmacies not in compliance with these practices or if you are solicited to participate in non-compliant activity, please report it to our Fraud Tip hotline: 866.216.7096 or by email to [email protected].
Thank you,
Provider Outreach Team
Express Scripts
