Pharmacy Provider Manual · 1. DEFINED TERMS The glossary below lists terms and definitions that may be relevant as background information when reading the pharmacy provider manual

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Pharmacy Provider Manual APPL ICABLE TO ALL PROVINCES AND TERRITORIES (EXCLUDING

QUÉBEC)

December 2019

Version 5.0

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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. 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

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DOCUMENT REVIS ION HISTORY

Version Date last revised Publication date Details

1.0 December 2010 December 2010 Revision

2.0 November 2012 November 2012 Revision

3.0 April 2016 April 2016 Revision

3.1 February 2019 April 2019 Revision

4.0 June 2019 July 2019 Revision

5.0 December 2019 December 2019 Revision

Note: The publication date takes precedence over the date last revised.









Table of Contents 1. DEFINED TERMS ...................................................................................................................................................................... 6

2. INTRODUCTION ......................................................................................................................................................................... 9

2.1. Purpose ........................................................................................................................................................................... 9

2.2. Terms ............................................................................................................................................................................... 9

2.3. Exemptions ...................................................................................................................................................................... 9

2.4. Role of Express Scripts Canada ................................................................................................................................... 10

2.5. Express Scripts Canada Services ................................................................................................................................. 10

2.6. Express Scripts Canada Clients ................................................................................................................................... 11

3. PHARMACY PROVIDER AGREEMENT ..................................................................................................................................... 12

3.1. Pharmacy Provider Agreement ..................................................................................................................................... 12

3.2. Liability Insurance and Indemnity ................................................................................................................................ 12

3.3. Pricing – Same Level Playing Field .............................................................................................................................. 13

4. AUDIT AND REVIEW PROGRAM.............................................................................................................................................. 13

4.1. Audit ............................................................................................................................................................................... 13

4.2. Audit Response ............................................................................................................................................................. 14

4.3. Provider Responsibility ................................................................................................................................................. 14

4.4. Review ........................................................................................................................................................................... 15

5. ADJUDICATION SYSTEM OVERVIEW ...................................................................................................................................... 16

5.1. Real-time Processing .................................................................................................................................................... 16

5.2. Adjudication System Functionality ............................................................................................................................... 16

5.3. Variations in Pharmacy Practice Management Systems (PPMS) ............................................................................... 16

6. ENROLMENT AND MODIFICATION TO PHARMACY PROVIDER INFORMATION .................................................................... 16

7. CLAIM REIMBURSEMENT PROCESS ..................................................................................................................................... 17

7.1. Pharmacy Provider Reimbursement ............................................................................................................................ 17

7.2. Net Reimbursement ...................................................................................................................................................... 17

8. CLAIM SUBMISSION PROCESS .............................................................................................................................................. 18

8.1. Claim Submission Requirements -- General ................................................................................................................ 18

8.2. Direct Electronic Claim Submissions ........................................................................................................................... 19

8.3. Deferred Claim Submissions ........................................................................................................................................ 20

8.4. Manual Claim Submissions – Claims Exceeding $9,999.99 ..................................................................................... 20

8.5. Compound Claim Submissions .................................................................................................................................... 21

8.6. Methadone and Suboxone® Claim Submissions ....................................................................................................... 22

8.7. Medical Cannabis Claim Submissions ......................................................................................................................... 22

9. CLAIM REVERSALS ................................................................................................................................................................. 22

9.1. Electronic Claim Reversals ........................................................................................................................................... 22

9.2. Deferred Claim Reversals ............................................................................................................................................. 23

9.3. Manual Claim Reversals ............................................................................................................................................... 23









10. DISPENSING QUANTITIES AND UNITS OF MEASURE ............................................................................................................ 23

10.1. Extended Supply -- Vacation Supply ............................................................................................................................. 23

10.2. Compliance Packaging ................................................................................................................................................. 23

10.3. Units of Measure -- Pack Size Project .......................................................................................................................... 24

11. PRESCRIPTION SAVINGS CARDS ........................................................................................................................................... 24

12. COORDINATION OF BENEFITS ............................................................................................................................................... 24

12.1. Provincial Coordination of Benefits .............................................................................................................................. 25

12.2. Private Coordination of Benefits .................................................................................................................................. 25

13. PROGRAMS ............................................................................................................................................................................. 26

13.1. Provincial Integration Program ..................................................................................................................................... 26

13.2. Drug Utilization Review ................................................................................................................................................. 27

13.3. Step Therapy Program .................................................................................................................................................. 29

13.4. Opioid Management Program ...................................................................................................................................... 30

14. OTHER FUNCTIONALITIES ...................................................................................................................................................... 31

14.1. Maximum Allowable Cost ............................................................................................................................................. 31

14.2. Substituting Medication................................................................................................................................................ 31

15. PRIOR AUTHORIZATIONS AND LIMITATIONS ......................................................................................................................... 32

15.1. Prior Authorizations ....................................................................................................................................................... 32

15.2. Coverage Limitations .................................................................................................................................................... 33

16. CONTACT US ........................................................................................................................................................................... 34

16.1. Express Scripts Canada Website for Health Care Providers ....................................................................................... 34

16.2. Provider Contact Centre ............................................................................................................................................... 34

17. OTHER CONTACTS .................................................................................................................................................................. 35

17.1. Canadian Pharmacists Association.............................................................................................................................. 35

17.2. 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 ...................................................................................................................................... 39

Appendix D Reimbursement Guidelines for Compounded Drugs in BC, MB, ON and SK ........................................................ 40









1 . D E F I N E D T E R M S

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.

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.

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









Term Definition

Day supply Number of days of treatment relative to the quantity dispensed for a

particular medication as indicated by the prescriber.

Deferred claim Claim for which the member pays the pharmacy provider for the entire

cost of the covered medication upon dispensing and the pharmacy

provider transmits this claim electronically to Express Scripts Canada.

DIN Abbreviation representing the drug identification number specific to a

particular drug in Canada.

Direct electronic claim Claim for which the pharmacy provider transmits the claim information

to Express Scripts Canada upon dispensing the covered medication

and receives a response from the Express Scripts Canada adjudication

system specific to the claim submitted.

A direct electronic claim is also referred to as an EDI (electronic data

interchange) claim, an electronic claim or a direct claim and is the type

of claim referenced in the most common use of the word “claim” in

this manual.

Formulary List of covered medication prepared by the government or a list of

covered medication prepared by Express Scripts Canada on behalf of a

client.

In writing Refers to a written communication rather than a verbal

communication, sent via fax or mail.

Intervention code A code that is required to indicate the reason for overriding a claim

rejection or a claim cutback, where applicable. Written documentation

to support the use of an intervention code is required. This can be

documented either directly on the prescription or on the hard copy of

the dispensing record or electronic version of the member’s profile, at

the time of dispensing.

Manual claim Claim submitted via fax or mail for processing, rather than

electronically.

Member Primary cardholder, spouse and eligible dependent(s) to whom the

benefit plan provided by an Express Scripts Canada client applies. A

member is also referred to as a patient.

Member ID card Printed identification information card issued by the ESC client to the

principal beneficiary on a benefit plan bearing the Express Scripts

Canada logo and the client’s logo.

Net reimbursement The amount payable by ESC following a deduction of

copayments/deductibles, where applicable, is referred to as a net

reimbursement or a net payment.

OPINIONS Online Product Identification Number Index of Nova Scotia.









Term Definition

Pharmacy practice management system (PPMS)

Software provided by the pharmacy provider’s software vendor used by

the pharmacy provider to capture all relevant data when dispensing

medication in accordance with the CPhA pharmacy claim standard

(CPhACS), the prescription and Express Scripts Canada procedures.

Pharmacy provider A provider bound by the terms and conditions detailed in the pharmacy

provider agreement. A pharmacy provider is also referred to as a

participating pharmacy, provider, a participating pharmacy provider or

a pharmacy professional.

Pharmacy provider manual Written description of practices, policies, rules, operational

requirements and procedures pharmacy providers and cannabis

providers are to follow as part of the Express Scripts Canada provider

network. The pharmacy provider manual is also referred to as the

manual or the pharmacy manual.

Benefits administrator Individual(s) in charge of administering benefit plan details for

members usually at the members’ place of employment.

Prescription drug program Includes claims administration and other pharmacy management

services provided to a Sponsor according to an agreement with

Express Scripts Canada, including any Formulary.

Primary cardholder Principal beneficiary of a benefit plan.

Product selection code A code to indicate the reason for no substitution on a claim or another

reason for the selection of the substituted product dispensed at the

pharmacy. The list of product selection codes was developed by CPhA

and may be revised from time to time. Subject to applicable laws and

regulations within the pharmacy provider’s province or territory, the

use of product selection codes must be supported by appropriate

documentation on the original prescription.

Provider remittance advice Statement indicating the claim(s) electronically adjudicated by the

Express Scripts Canada adjudication system during a particular

payment cycle for the associated pharmacy provider. It is also referred

to as the provider remittance statement, ESC statement or provider

statement.

Real-time processing (RTP) Processing of claims in real live time.

Service date The dispensing date for the covered medication.

Software vendor The entity that provides the interface (PPMS) used by a pharmacy

provider to capture all relevant data when dispensing medication

according to Express Scripts Canada procedures, the prescription and

the CPhA pharmacy claim standard.

Sponsor Any insurance company, employer or other organization having

principal financial responsibility for payment of Covered Medications

provided to members









Term Definition

Extemporaneous compound code Code used to designate the applicable compound type (such as an

injection, cream, et cetera) for an extemporaneous compound.

Usual and customary fee It is also referred to as the usual and customary dispensing fee, the

dispensing fee, professional fee, usual and customary professional fee

or U & C fee.

Usual and customary retail price The lowest retail price including the ingredient cost, markup and

professional fee of a covered medication in any transaction with the

pharmacy provider dispensing the covered medication in the quantity

dispensed, on the date that it is dispensed, including any discounts or

special promotions offered on such date.

2 . I N T R O D U C T I O N

2.1. Purpose

The pharmacy provider manual is a written description of practices, policies, rules, operational requirements and

procedures pharmacy providers and cannabis providers are to follow as part of the Express Scripts Canada

provider network. Any reference to a pharmacy provider is also applicable to a cannabis provider where applicable

to benefit plan design.

2.2. Terms

Terms and conditions governing the relationship between the pharmacy provider and Express Scripts Canada are

detailed in the Express Scripts Canada pharmacy provider agreement. This pharmacy provider manual

supplements and completes the terms and conditions of the Express Scripts Canada pharmacy provider

agreement.

Express Scripts Canada reserves the right to update this pharmacy provider manual as required. It is the pharmacy

provider’s responsibility to refer to the most recent version of the pharmacy provider manual.

Following a revision to the pharmacy provider manual, pharmacy providers will be sent a minimum 30-day written

advance notification of the revisions. A pharmacy provider has thirty (30) days from the date the pharmacy

provider manual is published to terminate the agreement with Express Scripts Canada, if the provider disagrees

with the changes to the pharmacy provider manual. If no notice of termination is received within thirty (30) days,

Express Scripts Canada will view this as a pharmacy provider’s acceptance of the revision(s).

Unless otherwise stated, all sections of the manual apply to all claim submissions and all pharmacy providers.

The pharmacy provider manual can be accessed via the Express Scripts Canada website portal for healthcare

providers: express-scripts.ca/health-care-downloads-and-resources.

2.3. Exemptions

This pharmacy provider manual does not apply to the province of Québec.







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This pharmacy provider manual does not apply to any claim processed through the Non-Insured Health Benefits

(NIHB) Program for Indigenous Services Canada (ISC). As the claim adjudicator for the Non-Insured Health Benefits

(NIHB) Program, Express Scripts Canada is pleased to support pharmacy providers across Canada as they provide

services to registered First Nations and recognized Inuit. Pharmacy providers interested in submitting any eligible

claim through the NIHB Program can enroll in the NIHB Program by fully completing the Express Scripts Canada

pharmacy provider agreement located on the Express Scripts Canada NIHB Claim Services website portal:

provider.express-scripts.ca.

NIHB Pharmacy Providers Contact

Website provider.express-scripts.ca

NIHB Provider Claim Processing Call Centre 1 888 511-4666

Monday to Friday: 6:30 a.m. to midnight (ET)

Saturday, Sunday and statutory holidays: 8 a.m. to

midnight (ET)

2.4. Role of Express Scripts Canada

Express Scripts Canada provides professional expertise and leading-edge information management systems and

technology to ensure high quality, cost-effective healthcare products and services for its clients including health

care claim adjudication services.

2.5. Express Scripts Canada Services

In the context of pharmacy benefit management, a claim adjudicator is mandated by its clients to receive, analyze,

audit and reimburse (as applicable) any claim submitted by pharmacy providers on behalf of a client’s members

(i.e., patients). A claim adjudicator is not an insurance company. As a claim adjudicator, Express Scripts Canada is

a third party to the relationship between a client and its members and does not interfere with the member-client

relationship.

Express Scripts Canada offers its clients a variety of services including:

• Active pharmacy benefit management services

• Audit and review services

• Benefit plan design and management

• Clinical programs

• The Express Scripts Canada pharmacy services

• Innovative, flexible, real-time electronic adjudication of healthcare claims

• Pharmacy network management

• Point of Service (POS) claim utilization review

• Provider communication services

• Provider contact centre

• Provider enrolment services

• Research







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• Retrospective analysis and simplified reporting

• Training and education

2.6. Express Scripts Canada Clients

Express Scripts Canada adjudicates pharmacy provider claims on behalf of these entities:

Client ID Client Name

02 Manulife Financial

07 Manion Wilkins & Associates Ltd.

11 Industrial Alliance

12 Desjardins Insurance

15 Non-Insured Health Benefits (NIHB) Program*

25 Teamsters National Benefit Plan

29 Humania Assurance Inc.

31 Ministère de l’Emploi et de la Solidarité Sociale (MESS)

32 STI Technologies Ltd. (STI)

34 TELUS Health, formerly Symbility Health Inc.

37 Cowan Insurance Group

38 Syndicat des Fonctionnaires Municipaux de Montréal (SFMM)

39 Coughlin & Associates Ltd.

40 RWAM

43 Manulife Affinity Markets

47 Benecaid

49 Group Medical Services (GMS)

50 GMS Insurance Inc.

53 Groupe Premier Médical(GPM)

55 Johnson Inc.

73 Excellence

90 Empire Life

*Note: The NIHB Program is not governed by this pharmacy provider manual.









3 . P H A R M A C Y P R O V I D E R A G R E E M E N T

3.1. Pharmacy Provider Agreement

The approval and execution of the applicable fully completed Express Scripts Canada pharmacy provider

agreement and its exhibits are required to become a participating pharmacy provider on the Express Scripts

Canada pharmacy provider network. Express Scripts Canada requires that each pharmacy provider fully complete,

sign and submit an Express Scripts Canada pharmacy provider agreement. Notwithstanding the foregoing, any

pharmacy provider that submits a claim and is reimbursed by Express Scripts Canada is to abide by this pharmacy

provider manual. This pharmacy provider manual supplements and completes the terms and conditions of each

Express Scripts Canada pharmacy provider agreement.

3.2. Liability Insurance and Indemnity

The pharmacy provider shall obtain and maintain, and shall cause the pharmacies to obtain and maintain, in full

force and effect and throughout the term of the Express Scripts Canada Pharmacy Provider Agreement such

policies of general liability, professional liability and other insurance of the types and amounts as are reasonably

and customarily carried by pharmacies with respect to their operations.

The pharmacy provider shall obtain and maintain, for itself and each pharmacy, or shall cause each pharmacy

provider to obtain and maintain during the term of the Express Scripts Canada Pharmacy Provider Agreement,

comprehensive general liability insurance coverage that is equivalent to the amounts outlined with the provincial

pharmacy regulatory body; or a minimum of $2,000,000 when not outlined by the provider’s provincial pharmacist

regulatory body per occurrence per pharmacy, including pharmacist's professional liability insurance, for protection

from claims for bodily injury and personal injury to members from pharmacy provider’s operation or the operation

of the pharmacies under the Express Scripts Canada Pharmacy Provider Agreement.

By signing the Express Scripts Canada Pharmacy Provider Agreement, the pharmacy provider represents that these

insurance requirements are being met. The pharmacy provider shall furnish or cause to be furnished not less than

thirty (30) days prior written notice to Express Scripts Canada in the event of termination or material modification

of any such policies of insurance. Upon Express Scripts Canada’s request, the pharmacy provider shall provide

Express Scripts Canada with evidence of such insurance coverage satisfactory to Express Scripts Canada. If the

insurance purchased to satisfy the requirements of this section is of the claims made variety, the pharmacy

provider shall purchase an extended period of indemnity so that Express Scripts Canada is protected from any and

all claims brought against Express Scripts Canada for a period of not less than three (3) years subsequent to the

date of termination of the agreement.

Express Scripts Canada shall not be liable or suffer loss for any claim, injury, demand or judgment of any kind

whatsoever arising out of the sale, compounding, preparation, dispensing, manufacturing labeling, consultation,

communication of information on the prescribed or recognized use of medication, use of any medication or any

service provided, records made or pharmacological study of such records preferred, by a pharmacy or the

pharmacy provider pursuant to the agreement. Regardless of the insurance coverage required, the pharmacy

provider shall indemnify, defend and hold harmless Express Scripts Canada, its officer, directors and employees

against the full amount of any and all loss, expense, claim, or damage arising out of or attributable to any of the

foregoing.









3.3. Pricing – Same Level Playing Field

We are aware that a number of pharmacies are providing reduced prices to our competitors which include a lower

U&C dispensing fee, lower ingredient cost and mark-up (on some products). In addition, our (insurer and TPA)

clients are receiving an increasing number of complaints from their plan members (your patients) buying

medications at these pharmacies, regarding unexpected out-of-pocket amounts.

Each Express Scripts Canada Pharmacy Provider Agreement with Express Scripts Canada states that pharmacies

cannot charge more for cash paying customers or competitors. As such, the total reimbursement to the pharmacy

provider by Express Scripts Canada and the plan member for the provision of a covered medication shall not

exceed the amount contracted for, or accepted as payment by such pharmacy provider from any other private

payer or cash paying customer for that covered medication.

As of June 1, 2012, Express Scripts Canada addressed all instances relating to unequal treatment including, but

not limited to auditing claims, to ensure compliance with our Express Scripts Canada Pharmacy Provider

Agreement and this manual.

Please note, preferred provider networks (PPNs) are a benefit management strategy commonly used by our clients and set up

within our adjudication system. The same level playing field principle does not prevent pharmacy providers from entering into

these separate, negotiated arrangements with our clients.

4 . A U D I T A N D R E V I E W P R O G R A M

Express Scripts Canada maintains an ongoing audit and review program as a service to its clients. Pharmacy

providers are to comply with the pharmacy provider agreement, the pharmacy provider manual, Express Scripts

Canada newsletters and any communication distributed or published by Express Scripts Canada when submitting a

claim, to minimize the risk of claim adjustments, claim reversals and recoupments.

Express Scripts Canada or a third party authorized by Express Scripts Canada (the auditor) can review and audit

any claim up to two (2) years from the last service date or for as long as the applicable statute(s) of limitation

allow. Where an audit is pending or in progress at a pharmacy location associated with a provider, the enrolment

process for a new pharmacy associated with the same provider may be impacted resulting in longer processing

times.

All claims are subject to audit regardless of whether a claim successfully adjudicates. Express Scripts Canada

reserves the right to audit any claim.

4.1. Audit

Express Scripts Canada may conduct the following audit activities:

4.1.1. Member Verification

Member verification letters are sent to members to validate service dates, receipt of prescription and specific

claim information.

4.1.2. Prescriber Verification

Prescribers are contacted to confirm selected prescriptions for which they were identified as the authorizing

prescriber. Prescriber verification letters are sent to validate prescription authorizations.









4.1.3. Claim Verification

Claim verifications involve the following procedures:

• Impacted claims are automatically flagged by the Express Scripts Canada adjudication system according to

predefined criteria.

• Flagged claims are analyzed relative to specific audit procedures.

• Following this analysis, Express Scripts Canada may reverse and reprocess improperly submitted claims

immediately and notify the pharmacy provider through the remittance advice associated with the reprocessing.

• For other flagged claims, Express Scripts Canada may request a copy of the prescription and computer-

generated hard copies of dispensing records, as part of the claim verification process. Complete, legible, full-

page view documentation is required. Providers have fourteen (14) calendar days from the date indicated on

the documentation request to provide the requested documentation.

• If the requested documentation is not available for review by the due date indicated on the request or if errors

are detected during the review, the audited claim may be reversed or adjusted.

4.1.4. Written Desk Audit

During a written desk audit, a selection of documentation is requested from the pharmacy provider for analysis.

Express Scripts Canada analyzes flagged claims relative to specific audit procedures. Following this analysis,

Express Scripts Canada may reverse and reprocess improperly submitted claims immediately and notify the

pharmacy provider through the remittance advice associated with the reprocessing.

4.1.5. On-site Audit

During an on-site audit, the Express Scripts Canada auditor visits the pharmacy to analyze a selection of submitted

claims for validation of the pharmacy provider’s records. A mutually acceptable date and time may be prearranged.

Following this analysis, Express Scripts Canada may reverse and reprocess improperly submitted claims

immediately and notify the pharmacy provider through the remittance advice associated with the reprocessing.

4.2. Audit Response

Pharmacy providers have thirty (30) calendar days to respond to audited claims. For all pharmacy provider audits,

if no response is received within thirty (30) calendar days (i.e., within the audit response period) to dispute the

audit findings, the audit is deemed final. If a response is received within the response period, Express Scripts

Canada reviews the documentation provided to support the dispute. Following this review, a final report will be

issued to the pharmacy provider indicating the final decision and any required compensatory adjustment, where

applicable. The audit response process (i.e., the audit appeal process) can be initiated by calling the Provider

Contact Centre or by sending a fax to the fax number indicated on the communication received by the provider, if

applicable.

4.3. Provider Responsibility

For all providers, the following considerations apply to the audit and review program:

• Responding to all audit requests may reduce the risk of recoveries and subsequent audits.

• The pharmacy provider must cooperate with Express Scripts Canada in all audit and review activities. The

pharmacy provider must cooperate and participate in all processes, audit systems and complaint resolution

procedures established by Express Scripts Canada.









• Pharmacy providers must permit Express Scripts Canada or a third party authorized by Express Scripts Canada

to inspect, review and reproduce, during regular business hours and without charge, any business

documentation, financial documentation, prescriptions and authorizations for any submitted claim. This

documentation can relate to dispensing medication to members or to the registration requirements to be a

pharmacy provider to members as Express Scripts Canada deems necessary to determine compliance as

outlined in the Express Scripts Canada pharmacy provider agreement, this pharmacy provider manual, Express

Scripts Canada newsletters and any communication distributed or published by Express Scripts Canada. The

original details on all documentation retained by the pharmacy provider should remain visible and legible.

• Failure to comply with any Express Scripts Canada audit and review quality assurance procedure may result in

an adjustment, reversal and/or recovery of any impacted claim reimbursements. Lack of compliance may also

result in the termination of the Express Scripts Canada pharmacy provider agreement at the sole discretion of

Express Scripts Canada.

4.4. Review

Express Scripts Canada may conduct reviews if there is a suspicion of high abuse, fraud or waste from a pharmacy

provider. Express Scripts Canada may withhold reimbursements to the pharmacy provider until the review is

completed. At the conclusion of a review where withheld reimbursements are deemed in excess of identified

discrepancies, the excess amount is disbursed to the pharmacy provider.

Express Scripts Canada may conduct any of the following reviews:

4.4.1. Written Desk Review

During a written desk review, specific documentation is requested from the pharmacy provider and compared with

the dispensing information received from in-house pharmacy provider(s) at Express Scripts Canada.

4.4.2. On-site Review

During an on-site review, an Express Scripts Canada auditor reviews a selection of submitted claims and examines

the pharmacy provider’s records for validation with the pharmacy provider requirements outlined in the ensuing

section. Express Scripts Canada may not provide notice of an on-site review. If Express Scripts Canada determines

that a provider has: (i) refused to cooperate in a review; (ii) acted in an inappropriate manner; (iii) caused any claim

to be submitted inaccurately under false pretenses; and/or (iv) submitted a discrepant claim for reimbursement,

Express Scripts Canada reserves the right to exercise any and all of the following options:

• Reverse the applicable claim(s) and recover the amount(s) payable;

• Recover excess reimbursements by deducting the excess amount from subsequent reimbursements or by

requiring immediate reimbursement from the pharmacy provider;

• Withhold subsequent reimbursements until sufficient reimbursements to recover any amounts payable are

collected;

• File a formal complaint with the applicable provincial college of pharmacy professionals, board or association

associated with the pharmacy provider;

• Initiate collection efforts to recover any amounts payable, if sufficient reimbursements are not repaid or cannot

be withheld; and/or

• Immediately terminate the Express Scripts Canada pharmacy provider agreement with the pharmacy provider.









5 . A D J U D I C A T I O N S Y S T E M O V E R V I E W

5.1. Real-time Processing

Real-time processing (RTP) refers to the capacity of the Express Scripts Canada electronic system to receive,

process and return the adjudication results of pharmacy provider claims automatically.

5.2. Adjudication System Functionality

The Express Scripts Canada adjudication system processes any electronic claim transmitted through the pharmacy

provider’s PPMS (pharmacy practice management system) and returns a response indicating whether the claim

was successfully adjudicated or not. The adjudication response is transmitted using the format specified by the

current CPhA Pharmacy Claim Standard.

5.3. Variations in Pharmacy Practice Management Systems (PPMS)

Exact messaging and options displayed to pharmacy providers may vary from those indicated in this pharmacy

provider manual depending on the pharmacy practice management system (PPMS) implemented by a pharmacy

provider’s software vendor. Software vendors may be best able to determine if the pharmacy practice

management system (PPMS) aligns with Express Scripts Canada terms to facilitate all claim submissions including

methadone claim submissions.

6 . E N R O L M E N T A N D M O D I F I C A T I O N T O P H A R M A C Y P R O V I D E R I N F O R M A T I O N

To join the Express Scripts Canada pharmacy provider network, please complete the pharmacy enrolment form

(i.e., registration form) available at express-scripts.ca/health-care-downloads-and-resources.

Express Scripts Canada will assign a unique provider number to each pharmacy provider, upon approval for

registration. This unique provider number is required on all correspondence with Express Scripts Canada, including

claim submissions and prior authorizations.

To amend pharmacy provider information, a pharmacy modification form must be completed and returned to

Express Scripts Canada in writing twenty (20) business days in advance of the change(s).

The following information can be updated using a pharmacy modification form:

• Address and mode of communication (fax, email or mail).

• Usual and customary fee (dispensing fee).

• Reimbursement information (i.e., to modify or set up direct deposit for reimbursements) – as a reminder,

Express Scripts Canada does not have the right to withdraw funds from a pharmacy provider’s bank account.

• Operating name – Operating names can be updated using a pharmacy modification form only when the legal

name or pharmacy ownership name remains unchanged.

• For changes to the legal name or pharmacy ownership name (including changes to the owner name(s), director

name(s) or other shareholder name(s)), please complete and submit the pharmacy enrolment form (i.e.,

registration form) available at express-scripts.ca/health-care-downloads-and-resources. A new provider number

may be issued in response to these changes. If a new provider number is issued, records associated with the

old provider number are transferred to the new provider number to allow for continuity in records management.

Pharmacy providers must notify Express Scripts Canada promptly in writing of any pharmacy acquisitions,

pharmacy closures and changes to the pharmacy provider’s membership in the respective pharmacy regulatory

bodies.











7 . C L A I M R E I M B U R S E M E N T P R O C E S S

7.1. Pharmacy Provider Reimbursement

Express Scripts Canada will reimburse pharmacy providers in a timely manner in accordance with the terms and

conditions of the applicable Express Scripts Canada pharmacy provider agreement and the pharmacy provider

manual.

7.2. Net Reimbursement

The pharmacy provider will receive reimbursement for:

• Services provided in relation to a covered medication.

• Other reimbursable services, as detailed in the applicable Express Scripts Canada pharmacy provider

agreement, any amendments to the same and this pharmacy provider manual. Applicable copayments and

deductibles will be subtracted from such reimbursements (the resulting amount is referred to as a net

reimbursement or a net payment).

7.2.1. Reimbursement Schedule

Pharmacy providers are reimbursed on a weekly basis unless the applicable Express Scripts Canada pharmacy

provider agreement indicates otherwise. If a reimbursement issue date falls on a statutory holiday, the

reimbursement is issued on the following business day.

7.2.2. Reimbursement Method

Direct deposit (electronic funds transfer (EFT)) is an environmentally friendly method for depositing pharmacy

provider claim reimbursements. It is the required reimbursement method for pharmacy providers.

7.2.3. Remittance Advice

The Express Scripts Canada remittance advice is a statement summarizing any claim(s) adjudicated during the

associated payment cycle, including reversals or adjustments conducted during that payment cycle. The

remittance advice also includes CPhA response codes associated with processed claim(s), where applicable. The

Express Scripts Canada remittance advice may be accessed electronically, where the provider is not associated

with a chain that has designated centralized access for its chain pharmacy providers. Available remittance advice

may be accessed via escstatement.ca.

Login credentials to access available remittance advice are issued after pharmacy providers become eligible to

submit claims (i.e., following the completion of the enrolment process). For security reasons, login credentials

cannot be sent by email. If a new provider has still not received login credentials after the standard mailing time

determined by Canada Post ™ for your address, please call the Provider Contact Centre to initiate an inquiry.

Where applicable, additional validation may be required and may impact the turnaround time for processing login

credentials.







http://www.escstatement.ca/



7.2.4. Reimbursement errors

Any reimbursements made to the pharmacy provider in excess or in deficit of the amount determined to be due by

Express Scripts Canada may be recovered following the identification of this error. This includes but is not limited

to excess or deficit amounts resulting from an error by either party, inaccurately submitted information, inadequate

supporting information and audit deficiencies. When identified, Express Scripts Canada may reverse and reprocess

such claims and will notify the pharmacy provider through the remittance advice associated with the period during

which the reprocessing occurred. If an under-reimbursement occurs, please call the Provider Contact Centre.

8 . C L A I M S U B M I S S I O N P R O C E S S

Claims may be submitted electronically through the Express Scripts Canada adjudication system or in writing (i.e.,

as manual claims).

8.1. Claim Submission Requirements -- General

8.1.1. Prescription Documentation Requirements

Express Scripts Canada requires an authorized prescription for any claim submitted for reimbursement. All claims

for items covered by the ESC client (including medication that typically requires a prescription, over-the-counter

medication and behind-the-counter medication) must be accompanied by a prescription. Each prescription must

include the following information:

• date of authorization;

• member’s complete name;

• drug name, quantity and direction for use;

• prescriber’s name and signature;

• number of refills and the interval between fills (if applicable); and the

• date that the authorization was received/signature of the receiving pharmacist (for verbal prescriptions).

Note: Any changes to the authorized prescription must be recorded directly on the prescription prior to processing

the claim. Data entry for all claim information must be consistent with the data on the prescription documentation.

8.1.2. Product Selection Code Requirement

Subject to applicable laws and regulations in the applicable province or territory of practice, the use of product

selection codes (section 14.2.3) must be supported by appropriate documentation on the original prescription.

8.1.3. Intervention Code Requirement

When a claim is submitted with an intervention code, written documentation to support the use of an intervention

code is required. The supporting information can be documented directly on the prescription, on the hard copy of

the dispensing record or on the electronic version of the member’s profile, at the time of dispensing.









8.1.4. Prescriber ID Reference Number Requirement

The required prescriber ID reference number is the prescriber’s valid unique prescriber reference ID number as

assigned by the respective provincial regulatory authority. Express Scripts Canada requires that pharmacists

provide prescriber ID information, where required by law. Where not required by law, pharmacy providers can take

reasonable steps to obtain the prescriber ID reference number assigned by the province. Failure to do so could

result in a potential audit review and claim recovery.

8.1.5. Pharmacist Prescribing Requirement

These conditions must be satisfied by a pharmacist prescribing:

• The pharmacist prescribing is licensed by and in good standing with the respective governing body and province

or territory of practice.

• The prescription is written within the context of the authorized prescriber’s scope of practice as determined by

the applicable provincial legislation.

• The pharmacist code field is populated with the license number of the pharmacist prescribing as approved by

their licensing body and the applicable CPhA prescriber reference ID number is indicated on each claim.

8.1.6. Actual Day Supply Requirements

The actual day supply must be indicated on each claim taking into consideration member dialogue and

professional discretion when prescription directions are not specific. If exact directions are not provided by the

prescriber (e.g., if the prescriber indicates “as directed” or “prn”), pharmacy providers may contact the prescriber

or make a reasonable assessment and submit the day supply based on:

• the prescriber’s verbal indications or the pharmacist’s assessment (which should be documented on the

original prescription in accordance with applicable legislation); and

• the quantity prescribed.

For all medication, the quantity dispensed must correspond to the quantity billed. For instance, if a 90-day supply

is dispensed, billing cannot be made in 30-day increments. All ninety (90) days must be billed at once.

8.2. Direct Electronic Claim Submissions

Direct electronic claims may be submitted and reversed electronically by the provider up to sixty (60) days from the

service date (i.e., date of service). For claims greater than sixty (60) days but less than 365 days, please call the

Provider Contact Centre. Please note that claims older than 365 days cannot be processed. The following

information must be indicated when submitting a direct electronic claim through the Express Scripts Canada

adjudication system:

Type of information Description

Member information Always refer to the member ID card when submitting a claim. All numbers (e.g., group

number, carrier number, member ID alphanumeric number) should match the exact

number of digits on the identification card, including leading zeros and trailing zeros.

Relationship code Confirm that the appropriate relationship code is entered for the primary cardholder,

spouse, or dependents respectively. Where applicable, ask the member to verify that

the spouse or dependent is covered by the benefit plan.









Type of information Description

Drug information Include the DIN of the covered medication, quantity dispensed, the day supply, the drug

and compounding costs, the usual and customary fee and the prescription number.

Express Scripts Canada accepts provincial drug plan pseudo-DINs including OPINIONS

pseudo-DINs.

Prescriber information Express Scripts Canada requires that pharmacists provide prescriber ID information,

where required by law. Where not required by law, pharmacy providers can take

reasonable steps to obtain the prescriber ID reference number assigned by the

province.

Claim amount Refers to the total amount billed for a specific covered medication in a specific quantity

including the drug cost, markup and professional fee.

8.3. Deferred Claim Submissions

Deferred claims are paid in full by the member at the time of dispensing. The pharmacy provider submits claim

information electronically to ESC and the information received from the pharmacy provider is communicated to the

ESC client by ESC.

8.4. Manual Claim Submissions – Claims Exceeding $9,999.99

Claims with a total amount submitted value that exceeds $9,999.99 cannot be adjudicated electronically due to a

CPhA Pharmacy Claim Standard restriction in the dollar field. These claims must be submitted manually.

Circumventing the manual claim submission process by splitting a claim into smaller claims is not allowed.

Currently, claims with a total amount submitted value that exceeds $9,999.99 are processed by dividing the total

quantity submitted into a number of equally split quantities. The number of quantity splits is determined by the

number of units of $9,999.99 in the total amount submitted.

For instance:

• If the total amount submitted represents three whole units of $9,999.99 (i.e., three units or more but less than

four units), the quantity submitted is split into three equal parts. One whole unit of $9,999.99 results in one

unit increase in the number of quantity splits.

• The ESC provider remittance advice displays each split quantity in the quantity column as a distinct claim

associated with a distinct Rx number at the time of adjudication.

• For any claim exceeding $9,999.99, submit the claim form for drugs over $9,999.99 (available at express-

scripts.ca/health-care-downloads-and-resources) via fax or mail:

Contact resources for claims over $9,999.99 Contact

Fax 1 844 744-8433











Contact resources for claims over $9,999.99 Contact

Mail Express Scripts Canada

Attention: Health Claims & Administration

10th Floor



Express Scripts Canada is committed to processing claims over $9,999.99 within one (1) business day. Claim

forms received before 3 p.m. (ET) will be processed on the same day. Claims received after 3 p.m. (ET) will be

processed the next business day. Some claims may require additional validation and may not fall within the

standard turnaround time. Alternatively, the member may pay for the claim and submit the claim information and

receipts directly to the ESC client for reimbursement, where applicable. Express Scripts Canada does not accept

any liability for the coverage of manual claims submitted by pharmacy providers. Claims are reimbursed according

to the benefit plan design for that covered medication for that member.

8.5. Compound Claim Submissions

Extemporaneous preparations (compounds) must not duplicate the formulation of a commercially manufactured

drug product and at least one of the active ingredients in the compound must be covered by the member’s benefit

plan when submitting a compound claim through the Express Scripts Canada adjudication system.

For a list of pseudo-DINs corresponding to active ingredients used for compounding, please see: express-

scripts.ca/health-care-downloads-and-resources. For compound claim submissions, indicate the DIN or pseudo-

DIN of the highest cost eligible ingredient and the extemporaneous compound code corresponding to the

medication type.

8.5.1. Extemporaneous Compound Codes

To help generate the correct compound code for extemporaneous compounds, select the appropriate compound

code value as indicated in the table below or use the applicable wording to describe the compound – whichever

option is provided by your PPMS interface:

Type of compound Compound code value

Topical cream 0

Topical ointment 1

External lotion 2

Internal use liquid 3

External powder 4

Internal powder 5

Injection or infusion 6

Ear/eye drop 7











Type of compound Compound code value

Suppository 8

Other (e.g., lozenge) 9

Note: The step therapy program and the drug utilization review (DUR) do not apply to compound claims.

8.5.2. Reimbursement Guidelines for Compounded Drug Claims

For the provinces of British Columbia, Manitoba, Ontario and Saskatchewan, pharmacy providers submit all claims

related to compounded drugs using the Express Scripts Canada reimbursement guidelines available in Appendix D.

These guidelines determine the maximum time charge allowed for each compounded drug type. For all other

provinces and territories, a flat fee applies to compounded drugs.

8.6. Methadone and Suboxone® Claim Submissions

Methadone and Suboxone® claims may be eligible for reimbursement where applicable to the benefit plan design.

When submitting methadone or Suboxone® claims, please note the following:

• do not include a compound code;

• indicate the day supply and the number of milligrams (mg) if using powder form or the volume in milliliters (mL)

if using liquid form (e.g., Methadose™);

• ESC does not reimburse an additional compounding fee above and beyond the pharmacy provider’s usual and

customary fee (i.e., professional fee);

• ESC allows one usual and customary fee for any witnessed dose and one usual and customary fee for the group

of carries (take-home doses). For instance, if a patient is prescribed one witnessed dose and six carries, the

pharmacy will be reimbursed for two fees: one for the single witnessed dose and one for the six carries.

8.7. Medical Cannabis Claim Submissions

Medical cannabis claims may be eligible for reimbursement under certain Prescription Drug Programs or benefit

plans administered by Express Scripts Canada. For a medical cannabis claim to be eligible for reimbursement, the

medical cannabis must be prescribed by an authorized health care practitioner and dispensed by a licensed

cannabis producer or distributor in accordance with all applicable cannabis laws and regulations. For medical

cannabis claim submissions, the quantity dispensed must be expressed in equivalent grams of dried cannabis.

9 . C L A I M R E V E R S A L S

9.1. Electronic Claim Reversals

Electronic claim reversals can be used to reverse a previously submitted electronic claim that has already been

reimbursed. Electronic claims can be reversed by the pharmacy provider in the ESC adjudication system if the

reversal is made within sixty (60) calendar days of the service date, as per the CPhA Pharmacy Claim Standard. A

reversed claim can be resubmitted as long as both the reversal and resubmission occur within sixty (60) days of

the service date.









9.2. Deferred Claim Reversals

Deferred electronic claims can only be reversed within the specified period indicated by an ESC client (i.e., the

carrier). Once this period has elapsed, deferred claims cannot be reversed by Express Scripts Canada. To

determine if a deferred claim can be reversed, please call the Provider Contact Centre.

9.3. Manual Claim Reversals

For manual claim reversals (i.e., for reversing a claim submitted by the pharmacy provider in writing), please call

the Provider Contact Centre.

1 0 . D I S P E N S I N G Q U A N T I T I E S A N D U N I T S O F M E A S U R E

Where applicable to benefit plan design, covered medication may be classified as maintenance or non-

maintenance to determine the maximum allowable day supply for each medication. For a new course of treatment

or for the first four months of coverage (whichever criterion is specified by the benefit plan design), the same

maximum allowable day supply generally applies to all covered medication regardless of their eventual

classification as maintenance or non-maintenance medication.

Maintenance medication may be dispensed in quantities corresponding to a maximum allowable day supply of

100 days, if authorized by the prescriber, unless the benefit plan states otherwise.

For non-maintenance drugs, the maximum quantity dispensed per DIN will be the lesser of:

• the amount prescribed; or a

• 34-day supply, if this limit is specified by the benefit plan design.

If a maintenance supply of a covered medication has not been dispensed to a member eligible to receive a

maximum allowable day supply, the following CPhA response code will be generated: KX – PATIENT IS NOW

ELIGIBLE FOR MAINTENANCE SUPPLY.

Note: Maximum allowable day supply specifications do not apply to compound claims.

10.1. Extended Supply -- Vacation Supply

An extended supply (i.e., a medication supply exceeding the benefit plan design’s day supply for that member for

the applicable DIN) may be permitted for members travelling out of their province of residence, if prior

authorization has been obtained where applicable to benefit plan design. Members seek prior authorization from

the ESC client (through their benefits administrator) to allow for a vacation supply of the applicable DIN in advance

of the claim submission. If the benefit plan design prevents an extended supply, the member may pay for the

entire prescription or for the portion of the prescription in excess of the allowable day supply and submit the claim

information and receipts to the ESC client for reimbursement of the outstanding amount, as applicable.

10.2. Compliance Packaging

Compliance packaging may be beneficial to members for the management of multiple medications. Express

Scripts Canada requires that the prescriber authorize the request for compliance packaging. The authorization

must be documented directly on the prescription or on the hard copy of the dispensing record or electronic version

of the member’s profile.









10.3. Units of Measure -- Pack Size Project

Express Scripts Canada may refer to provincial formularies or ESC client formularies when determining units of

measure in the Express Scripts Canada adjudication system. In particular, certain DINs require the use of specific

units of measure to avoid improperly submitting claims relative to the wrong unit of measure. Improperly submitted

claims may be subject to claim adjustments, claim reversals and the recoupment of reimbursement. For a

comprehensive list of past unit of measure updates, please see: express-scripts.ca/health-care-downloads-and-

resources. Pharmacy providers must be diligent when submitting claims for all medication including medication

dispensed in packages (e.g., inhalers, oral contraceptives and vaccines).

1 1 . P R E S C R I P T I O N S A V I N G S C A R D S

Express Scripts Canada adjudicates claims related to prescription savings cards, on behalf of certain ESC client(s).

Prescription savings cards offer financial assistance on brand name medication prescriptions and include the

following card types:

• Sample cards – the program pays the usual and customary fee (U&C fee) for the DIN as outlined on the card

and the plan does not cover any costs associated with the dispensed DIN (primary payer).

• Patient benefit and patient assistance cards -- the program pays a portion of the prescription price (payer of last

resort).

• Patient choice cards– the program pays the difference between the brand name DIN list price and the generic

DIN list price (secondary payer).

Savings cards may be coordinated with a patient’s insurance coverage, whether public or private. Pharmacy

providers must follow the recommendations indicated on the reverse of each card, when coordinating benefits.

Express Scripts Canada will reverse claims used with a prescription savings card(s) where the prescription savings

card(s) is coordinated with one or more additional prescription savings cards and coordination with additional

prescription savings cards is prohibited by the ESC client or by the issuer of a coordinated prescription savings

card.

1 2 . C O O R D I N A T I O N O F B E N E F I T S

The Express Scripts Canada adjudication system indicates that a coordination of benefits is required when a

combination of plan coverages (i.e., provincial and private or private and private) may apply to the claim.

Coordinating benefits reduces duplications in claim processing and ensures that the total amount paid in coverage

for a claim does not exceed 100% of the expenses incurred by the member.

Where members are eligible for provincial drug coverage, pharmacy providers are to coordinate claims with the

province as the first payer unless the province specifically states otherwise.

The first ranking insurer (i.e., the first payer or the primary payer) reimburses the claim according to its

reimbursement guidelines. Subsequently, the claim is transmitted to the second-ranking insurer (i.e., the second

payer or the secondary payer) for reimbursement on the outstanding claim amount according to its own

reimbursement guidelines. Finally, if applicable, the claim is transmitted to the payer of last resort for

reimbursement on the outstanding claim amount.

When the Express Scripts Canada adjudication system determines that a coordination of benefits is required, the

previously paid field must be populated with a previously paid amount even if the previously paid amount is $0.

Coordination of benefits in the Express Scripts Canada adjudication system, whether private or provincial, only

occurs when all portions of the same claim including previously paid portions are made by electronic claim

submission.











12.1. Provincial Coordination of Benefits

When the Express Scripts Canada adjudication system indicates that a provincial coordination of benefits (CoB) is

required, the DA intervention code must be included when submitting the claim to Express Scripts Canada for

adjudication. The DA intervention code is used to indicate that the claim has been coordinated with the provincial

plan.

12.2. Private Coordination of Benefits

When the Express Scripts Canada adjudication system indicates that a private coordination of benefits (CoB) is

required, the DB intervention code is used to coordinate the claim with the Express Scripts Canada adjudication

system regardless of whether the first payer plan is sponsored by an ESC client. If both private and provincial

coordination of benefits is required (i.e., Express Scripts Canada is the third payer in a situation that already

involved a public payer or private payer as first and second payers), the DB intervention code should be used

instead of the DA intervention code when submitting the claim to Express Scripts Canada.

Coordination of Benefits – Coverage Termination

• If the Express Scripts Canada adjudication system indicates that the first payer coverage is terminated (i.e.,

CPhA response codes C4 and CJ), the DB intervention code cannot be used to submit the claim. If different

valid member information applies, resubmit the claim using the updated information.

• If coverage is terminated, the member will have to pay for the claim, notify the benefits administrator and

submit the claim and receipts in writing directly to the first payer (plan). The outstanding amount is sent directly

to the second payer (i.e., the Express Scripts Canada client) for reimbursement – not to Express Scripts

Canada.

Coordination of Benefits – Spouse or Dependent

Several situations may apply when submitting claims to Express Scripts Canada that involve coordination of

benefits scenarios for spouses and dependents.

When a claim is transmitted to Express Scripts Canada as the primary payer for a spouse or dependent(s) and a

different plan should be the primary payer:

• The claim will be rejected with the following CPhA response code: C6 – PATIENT HAS OTHER COVERAGE.

• Process the claim through the appropriate primary payer first and transmit the outstanding amount to Express

Scripts Canada using the DB intervention code (to indicate that a different private coverage also applies).

When an Express Scripts Canada client is the primary payer for the cardholder, spouse and dependent(s) and the

coordination of benefits information for the spouse and dependents is not updated:

• The following CPhA response code is generated: C6 – PATIENT HAS OTHER COVERAGE.

• The claim cannot be submitted electronically.

• The claim and receipts are submitted in writing directly to the Express Scripts Canada client for manual

reimbursement.

• Please ask the member to contact the benefits administrator to change or update the coordination of benefits

information for the dependents.

When the primary payer for the spouse or dependent(s) is a non-Express Scripts Canada payer and Express

Scripts Canada is the primary payer for the primary cardholder only:









• If the first payer for the spouse or dependent(s) adjudicates electronically, transmit the claim to the primary

payer first and then to Express Scripts Canada using the DB intervention code with the outstanding claim

amount.

• If the first payer for the spouse or dependent(s) does not adjudicate electronically, request the spouse and/or

dependent(s) can pay for the cost of the claim upon dispensing. The claim and receipts are submitted in writing

directly to the first payer (plan) and the outstanding claim amount is sent to the second payer (plan) for

reimbursement.

1 3 . P R O G R A M S

Where applicable to the benefit plan design, the following programs may apply to a claim:

13.1. Provincial Integration Program

The Provincial Integration Program is designed to recognize two scenarios: when the submitted DIN is part of a

provincially funded program and may be designated as an exception drug by the provincial formulary or when the

submitted DIN is part of a provincial specialty or provincial disease program. The Provincial Integration Program

recognizes provincial coverage of the DIN, not the member.

The DA intervention code is used to indicate that the claim has been coordinated with the provincial plan in

general even if the previously paid amount (the amount covered by the province) for that particular claim is $0.

The Provincial Integration Program can be combined with the Ontario Drug Benefit (ODB) including Limited Use

drug products, Ontario Vacation Supply or the step therapy program, when submitting claims.

• If a pharmacy provider does not coordinate the claim with the provincial plan and does not indicate the DA

intervention code, the claim will be rejected with the following CPhA response code: C6 -- PATIENT HAS OTHER

COVERAGE.

• If the provincial plan is not paying any portion of the claim and it is submitted to Express Scripts Canada with

the DA intervention code and no additional intervention code, the claim will be rejected with the following CPhA

response code: 86 – CONFIRM PROVINCIAL DRUG COVERAGE FOR DIN. The DA intervention code must be used

in conjunction with the appropriate intervention code as outlined in the table below. If the Provincial Integration

Program is combined with ODB limited use, Ontario vacation supply or the step therapy program, replace DV,

DW and DX respectively (in the table below) with SV, SW and SX when coordinating claims.

Provincial Integration Intervention

Code

Scenario Action Required

DV–APPLIED TO THE PROVINCIAL

PLAN AND WAS APPROVED

Member applied to provincial plan for

coverage on this DIN and was approved.

Indicate the DA intervention code with

the DV intervention code to allow

processing.

DW--APPLIED TO THE PROVINCIAL

PLAN AND WAS REJECTED


coverage on this DIN and was rejected.


the DW intervention code to allow

processing.









Provincial Integration Intervention

Code


DX–APPLIED TO PROVINCIAL PLAN

AND THE DECISION IS PENDING


coverage on this DIN and is awaiting

decision.


the DX intervention code to allow

processing.

The DX and SX intervention codes can

only be used once. Attempts to use this

code in future claims for the same DIN

for the same member will result in the

rejection of the claim.

DY--PATIENT IS NOT ELIGIBLE FOR

PROVINCIAL PLAN COVERAGE

Member is not eligible for provincial plan

coverage in general, not just for the

submitted DIN.

The provincial integration program

recognizes provincial coverage of the

DIN, not the member. Indicate the DY

intervention code to show that

provincial plan coverage does not apply

to this member. The DA intervention

code is not required.

13.2. Drug Utilization Review

The Drug Utilization Review (DUR) analyzes a member’s history to determine if a previously dispensed covered

medication in the same therapeutic class or identical to the medication indicated on the claim is still active, based

on the quantity dispensed and standard recommended dosage schedule for the previously dispensed medication.

A Drug Utilization Review (DUR) edit occurs when the Express Scripts Canada adjudication system identifies a drug

therapy conflict and informs the pharmacy provider using the applicable CPhA response codes.

Express Scripts Canada is aware that the pharmacy provider may conduct its own Drug Utilization Review (DUR).

The Express Scripts Canada DUR, however, analyzes any claim transmitted via the Express Scripts Canada

pharmacy provider network for a member from anywhere in Canada.

Where applicable, pharmacy providers are to exercise professional judgment in applying an intervention code to

override DUR edits prior to dispensing covered medication. Pharmacy providers can apply an intervention code but

should only do so for a valid medical reason when an intervention has been conducted.

The two tables below summarize:

• CPhA response codes generated when a DUR identifies a drug therapy conflict and

• CPhA intervention codes that may be applied in these scenarios to override CPhA response codes, where









applicable.

DUR CPhA Response Code Scenario

MW or MY The dispensed DIN is the same drug (same chemical entity) as a drug dispensed by the

same pharmacy provider (MW) or another pharmacy provider (MY) and less than 67%

of the day supply of the previous dispensed covered medication has elapsed.

MX or MZ The dispensed DIN is in the same therapeutic class as a drug dispensed by the same

pharmacy provider (MX) or another pharmacy provider (MZ) and less than 67% of the

day supply of the previously-dispensed drug has elapsed according to the day supply

on the original claim.

ME A review of the member’s prescription history reveals that there may be potentially

severe or life-threatening drug interactions with another drug on the member’s profile

and the day supply of the previously-dispensed drug has not elapsed according to the

day supply indicated on the previous claim.

Pharmacy providers are to exercise professional judgment in applying an intervention code to override DUR edits

prior to dispensing a covered medication (i.e., a medication indicated as a benefit item for the plan coverage).

Pharmacy providers can apply an intervention code but should only do so for a valid medical reason when an

intervention has been conducted. Procedures for documenting intervention codes as indicated in the claim

submission requirements are required (section 8.1 – Claim Submission Requirements -- General). The table below

details CPhA intervention codes applicable to a DUR.

DUR CPhA Intervention Code Scenario

UA Consulted prescriber and filled Rx as written.

UB Consulted prescriber and changed dose.

UC Consulted prescriber and changed instructions for use.

UD Consulted prescriber and changed drug.

UE Consulted prescriber and changed quantity.

UF Patient gave adequate explanation. Rx filled as written.

UG Cautioned patient. Rx filled as written.

UI Consulted other source. Rx filled as written.

UJ Consulted other sources, altered Rx and filled.

UN Assessed patient, therapy is appropriate.









13.3. Step Therapy Program

The step therapy program encourages the use of proven and cost-effective therapeutic alternatives (step 1 drugs)

before stepping up to less cost-effective drugs (step 2 or step 3 drugs), where appropriate. Following adjudication

by Express Scripts Canada, if the step therapy program applies to the claim, the following CPhA response codes are

generated:

In both cases, a provider can verify that the plan member requires the prescribed drug due to lack of efficacy or

intolerance of the lower-cost alternatives. If it is determined that a member cannot use the step 1 drug, a CPhA

intervention code is required to override the rejection and process the claim:

Step Therapy CPhA Intervention

Code

Scenario

UP First-line therapy ineffective

UQ First-line therapy not tolerated by patient. This intervention code should not be used for

members under the age of 18 if the covered medication is inappropriate for that age

demographic.

For all claims related to the step therapy program, all audit requirements apply including intervention code

documentation requirements, where applicable (section 8.1.3).

13.3.1. Step Therapy Cognitive Fee

A pharmacy provider may be eligible for a step therapy cognitive fee when the pharmacy provider is successful in

switching a member to a lower step drug. The inclusion of this provision (i.e., a step therapy cognitive fee) is

contingent on the benefit plan design.

To claim the cognitive fee, the pharmacy provider submits a separate electronic claim indicating the PIN applicable

to the specific step therapy module in the DIN field and the pharmacy provider’s usual and customary cognitive

service fee in the drug cost field. A comprehensive list of step therapy modules and the PINs associated with

cognitive service fee claims is available at express-scripts.ca/health-care-downloads-and-resources.

Step Therapy CPhA Response

Code


QO--PREFERENCE OR STEP DRUG

IS AVAILABLE

The adjudication system finds claims for the

first step 1 drug or evidence that the patient is

already taking a step 2 drug (in a plan where

grandfathering applies). The claim is

accepted.

No action required.

SA--PREFERRED OR STEP DRUG

MUST BE SUBMITTED

If a member is starting therapy with a step 2

drug and has not already tried a step 1 drug or

the member is starting therapy with a step 3

drug and has not already tried a step 1 and a

step 2 drug, the following CPhA response code

is generated: SA – PREFERRED OR STEP

DRUG MUST BE SUBMITTED. The claim will be

rejected.

The pharmacy provider can contact

the prescriber to determine if a step

1 drug is acceptable or advise the

member to contact their prescriber

directly to determine if the

prescription can be changed.










Cognitive service fee reimbursements vary according to benefit plan design. Pharmacy providers submit their usual

and customary cognitive service fees and the Express Scripts Canada adjudication system will adjudicate the claim

according to benefit plan design. Express Scripts Canada may conduct a post-claim review of the cognitive fee

payment to verify the validity of the claim.

13.4. Opioid Management Program

Where implemented by benefit plan design, the Opioid Management Program aims to reduce opioid over-

dependency for members identified as opioid naïve by encouraging initial fill evaluations. Opioid naïve members

are members for whom a drug history review determines that a direct electronic (i.e., EDI) opioid claim has not

been submitted in the last 180 days through the ESC client (i.e., carrier) associated with the member’s current

claim.

Opioid Management Program -- Long-acting opioid module

For an initial fill of a long-acting opioid, a short-acting opioid is to be tried first before stepping up to a long-acting

opioid. If a claim is submitted for an initial fill of a long-acting opioid and a member is determined to be opioid

naïve, the claim will be rejected with the following CPhA response code: SA – PREFERRED OR STEP DRUG MUST BE

SUBMITTED. Please dispense a short-acting opioid first.

Pharmacists may be eligible for a cognitive service fee (PIN – 92000042) when they are successful in switching an

opioid naïve member from a prescribed long-acting opioid to a prescribed short-acting opioid during an initial fill.

Express Scripts Canada may conduct a post claim review of the cognitive service fee claim to validate the claim. On

a separate electronic claim, please indicate your usual and customary cognitive service fee in the drug cost field

and indicate the cognitive service fee PIN in the DIN field. The system will adjudicate the claim according to the

benefit plan design.

Opioid Management Program – Short-acting opioid module

For an initial fill of a short-acting opioid, a seven (7) day supply limit applies. If a claim is submitted for an initial fill

of a short-acting opioid that exceeds the seven day supply limit and a member is determined to be opioid naïve,

the claim will be cut back to the seven day supply limit with the following CPhA response code: OF – INITIAL RX DAY

SUPPLY EXCEEDED. Please dispense a seven-day supply.

Opioid Management Program – Intervention codes

Intervention codes may be used to override a short-acting opioid claim cutback or a long-acting opioid claim

rejection when:

first-line treatment is ineffective;

first-line therapy is not tolerated by patient;

members live in rural areas or have transportation difficulties accessing pharmacy services;

members have an opioid claim that was processed in the last 180 days, but not through a direct electronic

claim submission specific to the ESC client associated with the member's current claim; and

members require a vacation supply.

If you require an intervention code for the reasons indicated above or have further questions, please call the

Provider Contact Centre.









1 4 . O T H E R F U N C T I O N A L I T I E S

14.1. Maximum Allowable Cost

The maximum allowable cost module encourages the use of cost-effective DINs of similar efficacy and safety (i.e.,

therapeutic equivalents). For the maximum allowable cost module, the lowest cost DIN in a group of DINs

classified as therapeutic equivalents becomes the price reference for its group.

When a claim is submitted and this functionality (maximum allowable cost) is applicable, only the cost of the

lowest cost equivalent DIN (i.e., the lowest cost therapeutic equivalent in a group of DINs) will be covered for the

claim. The following scenario may apply:

Maximum Allowable Cost Module

CPhA Response Code

Scenario

QR – MAXIMUM ALLOWABLE

COST (MAC) PAID

The claim is cut back to reflect the price of the reference drug.

At the point of sale, the member has a choice to either obtain the originally-prescribed

drug and pay the difference in cost for the more expensive drug or have the lowest cost

therapeutic equivalent DIN dispensed with the prescriber’s approval.

14.2. Substituting Medication

Benefit plans may encourage generic substitution by offering better coverage for the equivalent generic medication

when compared to the brand name medication through mandatory generic substitution or standard generic

substitution.

14.2.1. Mandatory Generic Substitution

The benefit plan will only cover an amount corresponding to the lowest cost equivalent generic drug, even if the

authorized prescriber has indicated “dispense as written” or “no substitution” on the prescription. Members may

contact the client to obtain an exception for a mandatory generic substitution, if applicable.

14.2.2. Standard Generic Substitution

An equivalent generic drug is substituted for the brand name drug and a claim reimbursement amount is

generated based on the lowest cost equivalent generic DIN. Product selection codes, as detailed below, may apply

to the claim.

14.2.3. Product Selection Codes

Product selection codes are used to indicate the reason for selecting a different DIN from the DIN generated by the

Express Scripts Canada adjudication system when a standard generic substitution applies to the DIN according to

the benefit plan design. Product selection codes do not apply if a client has indicated that the benefit plan is a

mandatory generic plan (i.e., mandatory generic substitution applies).

If a different DIN from the DIN recommended by the Express Scripts Canada adjudication system is selected for a

reason other than a generic product substitution or a documented medical necessity, reimbursement for the

substituted medication may be disallowed. The table below details the product selection codes that may be

generated to describe scenarios where a product selection code applies:









Product Selection Code

Generated

Product Selection Rationale Scenario

1 Prescriber’s Choice The prescriber indicated no substitution on the

prescription.

2 Patient’s Choice The patient specified no substitution or has selected a

specific interchangeable medication in writing or by

initialing a written or printed statement.

3 Pharmacist’s Choice The pharmacist chose not to substitute the medication

on a prescription or has selected a specific

interchangeable medication when the prescription is

written without the no substitution stipulation.

4 Existing Therapy (prescription

renewal)

The pharmacist chose to continue the use of a brand

name or generic medication where variance in the

choice of medication may adversely affect treatment.

Blank Information is not required The product selection code is not needed.

1 5 . P R I O R A U T H O R I Z A T I O N S A N D L I M I T A T I O N S

15.1. Prior Authorizations

Covered medications may require prior authorizations (PAs) to ensure appropriate benefit plan utilization and the

optimal use of certain innovative costly drugs. Unless the member has obtained a prior authorization for a DIN that

requires a prior authorization, the claim will be rejected. When a prior authorization is required, the pharmacy

provider will receive one of the following CPhA response codes:

Prior Authorization CPhA

Response Code


LH The submitted DIN cannot be processed for

this member without a prior authorization

approved by Express Scripts Canada and

attached to the member’s profile

Express Scripts Canada is responsible

for the assessment of the request. See

the procedures below.

DX The submitted DIN cannot be processed for

this member without a prior authorization,

approved by the ESC client and attached to

the member’s profile

The ESC client is responsible for the

assessment of the request. See the

procedures below.

The CPhA response code (LH versus DX) differs depending on whether Express Scripts Canada or the Express

Scripts Canada client (e.g., the carrier) is responsible for assessing the prior authorization request. The message

generated to the pharmacy provider, accompanying both CPhA response codes (LH and DX), remains the same

regardless of who is responsible for assessing the request. It may be preferable for the member to complete the

prior authorization process prior to filling their prescription to confirm coverage for the medication. The table below

indicates the procedures for obtaining prior approval, as applicable:









Prior Authorization CPhA

Response Code

Scenario

LH Express Scripts Canada is responsible for the assessment of the request. A prior

authorization form is to be completed by the member and the authorizing prescriber

before it is returned to Express Scripts Canada in writing for assessment.

Whether the prior authorization request is granted or denied, Express Scripts Canada

will inform the member accordingly in writing. If the request is granted, Express Scripts

Canada will also update the electronic profile of the member.

The prior authorization form required when Express Scripts Canada is responsible for

the assessment of the request and the ESC prior authorization drug list are both

available at express-scripts.ca/health-care-downloads-and-resources.

DX The ESC client is responsible for the assessment of the request. The member contacts

the carrier directly to obtain the appropriate prior authorization form. The prior

authorization form is to be completed in full and returned to the client for assessment.

Whether the prior authorization request is granted or denied, the ESC client will inform

the member accordingly in writing. If the request is granted, the ESC client will also

update the electronic profile of the member.

15.2. Coverage Limitations

15.2.1. Coverage Limitations

All benefit plans have limitations on covered medication. The table below details some of these limitations:

Limitation Scenario

Fertility Drugs, Smoking

Cessation Products, Anorectics

and Anti-Obesity Drugs

Coverage for these medications varies by benefit plan, duration, quantity, et cetera. –

including no coverage at all.

Other limitations Limitations can also apply to quantity, specific DIN, day supply, et cetera.

15.2.2. Member-specific Limitations

Limitations may apply to specific members and not to other members covered by the same benefit plan and

include the following:

Limitation Scenario

Copayment Dollar amount per prescription that the member is responsible for paying out-of-

pocket, relative to benefit plan design.

Coinsurance Fixed percentage per prescription that the member is responsible for paying out-of-

pocket, relative to benefit plan.










Limitation Scenario

Deductible Cumulative fixed dollar amount to be paid by the member (primary cardholder, spouse,

or dependent(s)) before the client assumes any portion of the cost of covered

medication. Several classes of deductibles exist including:

Individual – each person in a family must satisfy a fixed amount.

Family – all individuals in a family accumulate toward the fixed amount.

Combined – each individual in a family accumulates an individual deductible, and each

individual’s deductible accumulates towards the family deductible.

Limited dispensing fee The limited dispensing fee feature allows for the reimbursement of dispensing fees on

adjudicated claims up until the member has met the limit on the number of paid

dispensing fees as determined by the benefit plan design for a specific DIN for that

member in a 12-month period. Once this limit is reached, dispensing fees on all

subsequent adjudicated claims will not be reimbursed.

Covered medications that may result in noncompliance issues (e.g., antipsychotics)

may be exempt from limited dispensing fees. Covered medications exempt from limited

dispensing fees do not have the limited dispensing fee feature in the Express Scripts

Canada adjudication system.

Other member-specific

limitations

Limitations can also apply to quantity, specific DIN, day supply, et cetera, for different

members based on the member’s profile or medication history.

1 6 . C O N T A C T U S

16.1. Express Scripts Canada Website for Health Care Providers

The downloads and resources portal of the Express Scripts Canada website contains several resources for

providers: express-scripts.ca/health-care-downloads-and-resources.

16.2. Provider Contact Centre

The Provider Contact Centre is for providers only. Member inquiries regarding benefit plan coverage or eligibility

(e.g., date of birth, coverage, et cetera) may be addressed to the benefits administrator affiliated with the member.

When contacting the Provider Contact Centre outside of regular hours of operation, leave a clear detailed voicemail

message including the associated provider number. Generally, a customer service representative will respond to

the call within one business day.

Provider Resource Contact

Website express-scripts.ca/providers

Provider Contact Centre 1 800 563-3274

Monday to Friday: 6:30 a.m. to midnight (ET)

Saturday, Sunday and statutory holidays: 8 a.m. to midnight (ET)

Fax 1 855 622-0669







https://express-scripts.ca/health-care-downloads-and-resources

https://www.express-scripts.ca/providers



Provider Resource Contact

Mail Express Scripts Canada

Attention: Provider Relations

10th Floor



1 7 . O T H E R C O N T A C T S

17.1. Canadian Pharmacists Association

For a copy of the current CPhA Pharmacy Claim Standard, please contact:

Canadian Pharmacists

Association

Contact

Email [email protected]

Phone 613 523-7877

Fax 613 523-0445

Mail 1785 Alta Vista Drive

Ottawa, ON K1G 3Y6

17.2. Software Certification/Network Communications

For inquiries regarding software certification or network communication issues, please contact:

Telus Contact

Phone 905 629-5703

Mail Attention: Erik Noolandi

5090 Orbitor Drive

Mississauga, ON L4W 5B5







mailto:[email protected]



1 8 . A P P E N D I C E S

Appendix A Sample Modification to Pharmacy Provider Information Form









Appendix B Common CPhA Response Codes

The table below indicates some of the most common CPhA response codes generated by the Express Scripts

Canada adjudication system:

CPhA Response Code Scenario Action Required

31 (indicating a group number

error)

The submitted group number on the

claim is invalid.

Verify that the group number is correct

including all leading and trailing zeros. If the

group number is correct and the claim is

rejected, call the Provider Contact Centre.

34 (indicating a patient DOB (date

of birth) error

The date of birth at the member level

is missing or the incorrect date of

birth was submitted on the claim.

If the submitted information is correct,

please ask the member to contact the

benefits administrator to verify the

member’s date of birth and associated

identifying information.

36 (indicating a relationship code

error)

The incorrect relationship code was

submitted by the pharmacy provider.

OR

The member is not enrolled or the

submitted information does not

correspond to the current member

record.

OR

The claim is submitted for the spouse,

but the spouse is not covered under

this plan.

The claim is submitted for an

underage dependent, but underage

dependents are not covered under

this plan.

OR

The claim is submitted for an overage

dependent, but overage dependents

are not covered under this plan.

OR

The claim is submitted for a disabled

dependent, but disabled dependents

are not covered under this plan.

Verify the relationship code by confirming

with the member ID card. If the submitted

relationship is correct, please ask the

member to contact the benefits

administrator to modify the relationship

code or verify coverage.









CPhA Response Code Scenario Action Required

37 (indicating a patient first name

or middle name error)

An incorrect first name or middle

name was submitted on the claim.

Verify the first name submitted by

comparing the information submitted with

the Member identification card including

any middle name. If the submitted

information is correct, please ask the


administrator to modify the member’s first

or middle names in the adjudication

system.

40 (indicating a patient gender

error)

The submitted gender on the claim is

incorrect.

Verify the gender submitted by comparing

the information submitted with the Member

identification card. If the submitted

information is correct, please ask the


administrator to modify the gender in the

adjudication system.

56 (indicating a DIN /GP # /PIN

error)

The submitted DIN/GP number does

not exist in Express Scripts Canada’s

adjudication system or is no longer

active.

OR

The claim was submitted with an

invalid compound number.

OR

There is no DIN pricing for the

province, or the service date is not in

the DIN coverage.

Verify that the DIN or GP# is still active. If

the submitted information is correct, please

call the Provider Contact Centre.

A3 (indicating that an identical

claim has been processed)

The claim has the same DIN or RX

number as a claim submitted for the

member in the last three days. The

claim is rejected because of duplicate

payment.

Verify that the service date on the claim is

not within three days of the service date for

a previous claim for the same DIN for this

member. If the submitted information is

correct, please contact the Provider Contact

Centre.









Appendix C Sample Remittance Advice









Appendix D Reimbursement Guidelines for Compounded Drugs in BC, MB, ON and SK

Quantity Number of ingredients Time allowed (in minutes) I. Creams, Ointments, Lotions

Quantity Number of ingredients Time allowed (in minutes)

1-15 g 2 4 3 6 4 8

16-25 g 2 6 3 8 4 10

26-50 g 2 8 3 10 4 12

51-100 g 2 10 3 12 4 14

101 g or greater or high # of ingredients 2 14 3 16 4 18 5 20 6 22 7 24 8 26 9 28

10 30

II. Capsules, Tablets, Suppositories


1-10 2 26 3 28 4 30

11-25 2 30 3 32 4 34

26-40 2 32 3 34 4 36

41-65 2 34 3 36 4 38

66-80 2 36 3 38 4 40

81 or greater 2 38 3 40 4 42

III. Liquid to Liquid


0-500 ml 2 2 3 3 4 4

501-1000 ml 2 4 3 5 4 6

1001 ml or greater 2 6 3 7 4 8

IV. Capsules/Tablets to Liquid










Quantity Number of ingredients Time allowed (in minutes) 1-10 caps/tabs N/A 10

11-25 caps/tabs N/A 15



66 caps/tabs or greater N/A 30

V. IV Bags


1 (any size IV bag) 2 10




VI. Triple Mix (alprostadil, papaverine and phentolamine)


25 ml or less N/A 30

25-100 ml N/A 45

101 ml or greater N/A 60







Documents

Pharmacy Provider Manual · 1. DEFINED TERMS The glossary below lists terms and definitions that may be relevant as background information when reading the pharmacy provider manual