In the past few weeks, Express Scripts, one of the nation’s largest PBMs, issued a reminder to pharmacies about the need to follow copayment collection guidelines.  The reminder was issued by the company’s Special Investigations Unit (SIU) after multiple network providers were found to be missing copayment collection documentation.

The Express Scripts notice reminds pharmacies that copayment collection and documentation requirements are detailed in the Provider Manual issued to each participating pharmacy.  Key provisions include:

  • Section 2.3:  Pharmacies agree to collect the full copayment from patients, and the copayment cannot be changed or waived unless required by law.
  • Section 2.4:  Proof of Service requirements are outlined, including details for point of sale (POS) receipts that indicate the price paid by the patient. Documentation that meets     this requirement includes:
    • Credit card receipts.
    • POS receipts indicating cash payments.
    • Copies of cancelled checks.

The Express Scripts reminder advises that failure to collect copayments from one or more members can result in termination.  Express Scripts may utilize any number of resources to detect possible instances of non-payment, including audit, investigation, and member statements, among other sources.

The Special Investigations Unit encourages anyone with information about pharmacies not in compliance, or anyone solicited to participate in non-compliant activity, to contact the Express Scripts Fraud Tip hotline.  The hotline can be accessed by phone, (866) 216-7096, or via email, [email protected].

PrimePOS™ and PrimeRxPAY™ – Seamless Copayment and Records Management

The PrimeRx™ pharmacy management system helps pharmacies ensure compliance with all PBM copay requirements.  The system’s PrimePOS™ point of sale and PrimeRxPAY™ modules facilitate seamless copay management with capabilities that include:

  • PrimePOS™ enables fast, accurate point-of-sale transactions with all records documented and stored within PrimeRx™.
  • Each patient’s account includes updated transaction histories.  This includes a record of payments for all transactions.
  • The system tracks the method of payment for each transaction.
  • Pharmacies can easily request reports that detail comprehensive copayment transaction details. Reports can be requested for a specific PBM, for example, or by payment  method, for select patients, or for a certain period, among many other topics.
  • PrimeRxPAY™ allows for remote copay payments. The pharmacy transmits a notice to a patient, via email or SMS/text, advising that a copayment is due. The message includes a link that the patient can access to submit a credit card payment. Once the payment is complete, a record of the transaction is seamlessly stored within the PrimeRx™ system.

Copay collection is an essential part of pharmacy management.  Rely on PrimeRx™ for seamless transactions and recordkeeping, as well as compliance with all PBM copay requirements.