Express Scripts (PBM)

Express Scripts, now part of Cigna's Evernorth division, is one of the three largest PBMs in the U.S. Express Scripts manages pharmacy benefits including formulary management, prior authorization, and specialty pharmacy services. They operate Accredo as their specialty pharmacy for high-cost medications.

Common Denial Patterns

• •National Preferred Formulary (NPF) restrictions — drug not on preferred tier
• •Step therapy protocol not completed per Express Scripts clinical criteria
• •Specialty drug requires Accredo specialty pharmacy
• •Quantity limits or dose optimization protocols
• •Drug excluded from employer's customized formulary

Step Therapy Approach

Express Scripts maintains multiple formulary tiers (National Preferred Formulary, Basic, etc.) with varying step therapy requirements. Step therapy is integrated into the claims adjudication system. Express Scripts has been a leader in biosimilar-first and value-based formulary design.

Appeal Process

Like other PBMs, appeals are primarily handled through the sponsoring health plan. Express Scripts provides clinical review support and peer-to-peer capabilities. For Cigna-insured members, the appeal process integrates with Cigna's standard appeal procedures.

Tips for Appealing Express Scripts (PBM) Denials

1. 1.Identify whether Express Scripts or the health plan handles your specific drug's PA — it depends on the plan design
2. 2.If Accredo is required as the specialty pharmacy, work with them on PA coordination
3. 3.Express Scripts' formulary exclusion list is published annually — check if your drug is excluded before prescribing
4. 4.For employer-sponsored plans, the employer may have customized the Express Scripts formulary — check with HR
5. 5.Express Scripts peer-to-peer reviews are available through the health plan