The Tennessee Department of Commerce and Insurance published its audit of Express Scripts for activity in 2023 and found many areas of noncompliance that harmed community pharmacies. Among the many disturbing findings, none of the 116 randomly selected claims to low-volume pharmacies received the enhanced dispensing fee as required. The audit found many egregious examples of ESI reimbursing its owned or affiliated pharmacies at much higher rates than those not owned or affiliated with ESI, also contrary to law.
ESI was shown to be non-compliant in nearly every aspect of the state's appeals process, including providing required information and meeting timelines. Initial reimbursement appeals were denied 83 percent of the time by ESI, but when the claims were submitted to the state for external review, 85 percent of those claims were overturned and paid more by an average of $60.29 or 64 percent.
These audits are the result of authorities granted to the department via H.B. 2661 in 2022 and then implemented with robust rulemaking by the department in 2023. ESI was one of five PBMs audited by the department in 2024.
The Tennessee Pharmacists Association issued a call to action in response to the audit findings, urging policymakers and legislators in Tennessee and Congress to strengthen and enforce PBM reform legislation. It also said employers and health plan sponsors should critically evaluate the value offered by PBMs and ensure the value is delivered.
