Community Pharmacies Opposed Changes

WASHINGTON — It’s a case of bad news-good news: TRICARE beneficiaries, as of Oct. 1, have fewer options for getting certain prescriptions filled, but their costs are lower.

As mandated by the 2015 National Defense Authorization Act, beneficiaries who take brand-name maintenance medications must fill their prescriptions at military treatment facilities or through TRICARE’s mail-order pharmacy. Generics and medications for acute illnesses can still be filled through retail pharmacies.

TRICARE beneficiaries received a letter in September explaining the new rule and instructions for making the transition from a retail pharmacy to either an MTF or the mail-in program.

Beneficiaries who fill brand-name prescriptions for a maintenance drug at a network retail pharmacy after October 1 will receive another notice of the new policy. After one more courtesy refill at a retail pharmacy, they will incur the full price of the medication unless they switch to the mail-order program or get refills at a military treatment facility (MTF), according to the TRICARE website.

Last spring, VA Secretary Bob McDonald, center, and medical advisor Dr. Baligh Yehia toured the Northeast Consolidated Mail Outpatient Pharmacy with facility director Chris Conisha. VA photo by Victoria Dillon

Last spring, VA Secretary Bob McDonald, center, and medical advisor Dr. Baligh Yehia toured the Northeast Consolidated Mail Outpatient Pharmacy with facility director Chris Conisha. VA photo by Victoria Dillon

The initiative should produce significant savings for both beneficiaries and the DoD, according to TRICARE officials.

“Moving just one brand name formulary maintenance medication from retail to home delivery saves a beneficiary up to $176 per year,” said George Jones, PharmD, chief of TRICARE Pharmacy Operations. In addition, “the government saves roughly 17.6% on prescriptions filled through home delivery compared to retail pharmacies. The department estimates this will lead to $16.5 million in savings for beneficiaries and $88 million savings for the DoD in the first year.”

The DoD started piloting the program last year among TRICARE for Life (Medicare-eligible) beneficiaries. That program, which ran from March 2014 through October 1, 2015, enrolled more than 200,000 beneficiaries and saved the DoD more than $130 million as of August 2015, Jones said. At the same time, beneficiaries saved about $28 million per year through lower copays.

The move was strongly opposed by pharmacy groups such as the National Association of Chain Drug Stores (NACDS).

In congressional testimony last year, NACDS emphasized the benefits of local pharmacies, saying it “supports cost-savings initiatives that preserve patient choice, but threatening beneficiary access to prescription medications and their preferred healthcare provider will only increase the use of more costly medical interventions, such as physician and emergency room visits and hospitalizations.”

In addition, NACDS pointed out that TRICARE beneficiaries who use mail order will miss out on medication counseling and medication therapy management (MTM) provided by pharmacies to their customers.

“Policymakers have begun to recognize the vital role that local pharmacists can play in improving medication adherence,” NACDS said in its statement.

Early Complaints

Despite early complaints about the change, most beneficiaries in the pilot said they liked the home-delivery option, once they tried it. “We often find beneficiaries initially resistant to change, but, as they gain more experience with home delivery, they find it satisfactory and are pleased with the savings and convenience,” Jones noted.

The TRICARE Home Delivery program boasts a 96% beneficiary satisfaction rate and has a 99.997% accuracy rate for dispensing medications, he added.

After a year of using home delivery or a military treatment facility to fill their prescriptions through the pilot program, beneficiaries had the option to switch back to using a retail pharmacy. “One metric of the pilot’s success was the use of the opt-out feature: Fewer than 500 beneficiaries (less than 0.25%) chose to exercise this option,” Jones said.

That level of satisfaction might be driven by two factors: cost and convenience. In addition to having lower copays, the mail-order program and military treatment facilities allow beneficiaries to receive a 90-day supply of drugs rather than just 30 days, which make them more convenient ways to fill prescriptions for maintenance medications.

The pilot program found that more than 90% of prescriptions for the target population moved to the home-delivery program. Jones said he expects similar results with the expansion to all TRICARE beneficiaries.

Yet, the program will not be suitable for everyone. Exemptions include individuals living abroad and active duty forces, who should continue to follow their service’s policies for filling prescription drugs.

Those with other health insurance that includes prescription drug coverage also are exempt. The TRICARE website notes that “typically, you can’t use home delivery when you have other health insurance” unless the other plan lacks pharmacy benefits, does not cover the prescribed drug or has a benefit cap that has already been met.”

Waivers also might be provided to individuals on a case-by-case basis. Jones noted that the most common exemption in the pilot program was for beneficiaries who lived in nursing homes for whom it was not practical to receive medications through the mail.

Express Scripts, the country’s largest pharmacy benefit manager, handles the mail order prescription delivery program, and the increased volume from TRICARE prescriptions is not expected to noticeably affect the speed or quality of the home delivery program, according to Jones.

Prescribers and pharmacists should advise beneficiaries that, if they want to have their prescriptions filled through the mail-order service from the start, they can ask that the medication be e-prescribed to the Express Scripts Mail Pharmacy or faxed to the mail-order service. Alternatively, beneficiaries can call the TRICARE Member Choice Center or mail in a registration form, available on the TRICARE website.

TRICARE noted that not all MTFs have all drugs on the TRICARE formulary, so beneficiaries should be advised by prescribers to call ahead to verify availability and find out how to transfer their prescriptions, if they would rather not use the mail-order service.

Beneficiaries can monitor the status of their medications and expected delivery date online or by calling Express Scripts. Questions about which medications fall under the brand-name maintenance category can be answered by calling Express Scripts customer service at 877-363-1303 or consulting TRICARE’s website: