By Annette M. Boyle
ALEXANDRIA, VA – A pilot program that requires use of mail order or military pharmacies for certain maintenance medications taken for chronic conditions has sparked a firestorm of controversy, upsetting community pharmacists and some legislators.
TRICARE leadership points out, however, that the program was mandated by Congress as part of the 2013 National Defense Authorization Act and that the issue is out of their hands.
In April,nine congressmen wrote to Assistant Secretary of Defense for Health Affairs Jonathan Woodson, MD, to express concerns about limitations imposed on TRICARE for Life beneficiaries.
“The structure for the pilot program was included in the congressional mandate,” according to William Blanche, TRICARE Pharmacy program manager. “Whether it is optimal is not relevant. There are options if mail order is an issue for a beneficiary and a waiver process in place if home delivery would be a problem.”
TRICARE for Life provides military healthcare coverage, secondary to Medicare, to TRICARE beneficiaries over age 65. Under the five-year pilot program that started in March, TRICARE no longer will pay for brand-name maintenance medications filled at a retail pharmacy. Initial and refill prescriptions for drugs such as antibiotics and pain medications taken for acute conditions may be filled at retail pharmacies, however, as can generic medications, even for chronic conditions.
Beneficiaries affected by the program received notices in February and March. TRICARE offered two courtesy fills of affected drugs through a retail pharmacy. After that, those who do not use a military pharmacy or the mail-order program will be responsible for the full cost of their medications.
In their letter, the legislators expressed concern that “many TRICARE for Life patients who prefer to get their prescriptions from a community pharmacist have seen their options limited.”
The letter was signed by representatives on both sides of the aisle, including Walter Jones (R-NC), Dave Loebsack (D-IA), Austin Scott (R-GA), John Garamendi (D-CA), Doug Collins (R-GA), Rick Larsen (D-WA), Lynn Westmoreland (R-GA), Sam Farr (D-CA) and Joe Courtney (D-CT).
The National Community Pharmacists Association (NCPA) also sees the pilot program as problematic. “We have two words to describe our position: concern and irony,” said NCPA Chief Executive Officer B. Douglas Hoey, RPh. “It’s ironic that we say ‘thanks for fighting for our freedom, but you don’t have freedom of choice for your prescriptions.’”
The legislators noted that “community pharmacists provide invaluable face-to-face counseling services and are trained to identify potential prescription drug abuse, which is a matter of increasing concern across the nation.” Further, they expressed concern about a “disconnect in care” that might occur if beneficiaries receive care for acute conditions and certain preventive services from their local pharmacist and use the mail-order pharmacy for maintenance medications.
“Whether patients use a military treatment facility pharmacy, a community retail pharmacy or mail order, their medical history is stored centrally,” Blanche told U.S. Medicine. “If there is an interaction with other medications, that’s reported to the pharmacist in real-time. The pharmacist may call the physician to explain the potential interaction and get permission to fill the prescription as written or change it. With each delivery, patients receive an information sheet about their medications and potential side effects and, if they have questions, a pharmacist is available by phone 24/7 to handle calls.”
The option to make a telephone call is not the same as getting the attention of a local pharmacist when a prescription is refilled, Hoey pointed out. A pharmacist who regularly fills a patient’s prescription gets to know the patient and “may notice adherence issues if the prescription isn’t being refilled as expected. They might ask about side effects or suggest alternatives. Without that connection, the patient may fall through the gap in care created by multiple healthcare and pharmacy providers. They won’t get the care that they deserve.”
Controlled medications, those most likely to be abused, are not available for home delivery, but Hoey noted that doesn’t necessarily keep packages from being intercepted by drug-seekers who don’t know what’s being shipped. “That can be dangerous for the person intercepting and the person who doesn’t receive their drugs for chronic care.”
Sending medications through the mail also might introduce other safety issues, according to Hoey. “Manufacturers recommend storing drugs at room temperature. If it’s 80oF outside, it could be 100oF to 120oF inside a mailbox.” Depending on the medication, the heat could potentially degrade the active ingredients.
Both the legislators and Hoey said the cost savings associated with mail order might be overstated because auto-shipping of prescriptions might continue, even though a patient has changed or discontinued a medication.
“We have hundreds of photos of piles of unused medications shipped by TRICARE or the VA after a patient’s therapy changed to a different medication,” Hoey said. “Sometimes patients do not use supplies as fast as expected, so they end up with unnecessary inhalers or diabetes test strips. In some cases, the patient is deceased but the shipments keep coming despite overtures from the spouse.”
Despite these issues, the great majority of TRICARE beneficiaries report high satisfaction with the mail-order pharmacy, Blanche said. “When we asked our beneficiaries if they’re satisfied with the service they receive from the TRICARE Mail Order Pharmacy, almost 90% told us they were either completely or very satisfied, and overall 96% were satisfied.”