Express Scripts modifies Medicare performance bonus pool process to continue focus on quality while improving cash flow to pharmacies

two pharmacists

In the shift to value-based care, Medicare plans are rewarded for good clinical performance and penalized for poor performance. To help increase the quality of the prescription drug benefit while keeping cost-sharing and premiums affordable for beneficiaries, Medicare plans can elect networks of pharmacies participating in Express Scripts performance-based networks that feature a bonus pool. This bonus pool pays higher-performing pharmacies based on improved clinical outcomes such as improved adherence rates.  

In response to drug price inflation by pharmaceutical manufacturers, industrywide disruptions earlier this year, and feedback from pharmacies, Express Scripts is modifying its current Medicare Part D bonus pool process. Express Scripts will no longer collect bonus pool fees from pharmacies for claims on or after June 14, 2024. Express Scripts will accelerate reimbursement for the entirety of bonus pool fees collected from pharmacies on claims with a service date of January 1, 2024, through June 13, 2024. Additionally, Express Scripts will fund the bonus pool to continue driving pharmacy focus on improved clinical outcomes.

“We view financial incentives for pharmacies as an effective way to drive performance around beneficiary adherence and reward those that consistently exhibit high performance around the metrics CMS has identified as important indicators of quality,” said Charlie Parker, vice president, Retail Network and Contracting, Express Scripts. 

CMS has not raised compliance concerns with utilizing a bonus pool structure to incentivize clinical performance for improving patient outcomes. CMS has requested the payments of the bonus pool be reported according to CMS guidelines and is supportive of the adjustment Express Scripts is making. The contributions made to date by pharmacies in the Medicare bonus pool have been separated from pharmacy reimbursement and dispensing fees. No portion of these fees were ever retained by the Part D sponsor or Express Scripts.