Doris Spatz takes the Kiskali pill once a day to keep her metastatic breast cancer under control. As a patient of the Department of Defense Health System, he can fill routine prescriptions without a copay at a military pharmacy but also has the option of using a regular pharmacy through Tricare, the Department of Defense’s private health care program.
Spatz found a local pharmacy in his Alexandria, Virginia, neighborhood and obtained life-saving medication there.
That is, until Oct. 24, when Express Scripts, Tricare’s pharmacy benefit manager, dropped about 15,000 pharmacies from its network. Many of them were small, independent pharmacies, such as Neighborhood Pharmacy in Del Ray, where Spatz was a customer.
According to Dr. Michael Spatz, Doris’ husband, the decision created problems because breast cancer drugs are not carried in every pharmacy. And some large chains require patients to use a branch of their business known as a specialty pharmacy for expensive or scarce drugs for complex diseases.
“Express Script told us, ‘You can just go to CVS,'” says Michael Spatz. “But it was kind of a mess because you can’t just go to CVS and get $1,500 worth of medicine. You have to be in their special pharmacy system.”
About 27% of all pharmacies in the TriCare network are no longer covered, affecting more than 400,000 military beneficiaries. The move has upset consumers and many independent pharmacies and raised concerns among some service member advocates and lawmakers, particularly in rural states who feel it disproportionately affects rural veterans.
In a September letter to the Defense Department, U.S. Sen. John Tester (D-Mont.), chairman of the Senate Veterans Affairs Committee, said: “People can no longer rely on their local pharmacy for essential medications and in-person access. Counseling pharmacists, they would be forced to drive long distances to find corporate in-network pharmacies or join Express Scripts’ mail delivery program. It is unacceptable.”
Many of the affected pharmacies knew they would be dropped from the network at the end of the year because they did not comply with Express Scripts terms, which included lower reimbursement rates. But they were surprised to be kicked out initially, said Rona Houser, senior vice president for policy and pharmacy at the National Community Pharmacists Association. “It was a very stupid rollout of this new network and unfortunate, ultimately, for patients,” he said.
The Military Officers Association of America, an advocacy group for active-duty and retired personnel, said it is pushing to reverse the decision.
While acknowledging that the Defense Department is under pressure to control health care costs, Karen Rudisuelli, the association’s health government relations director, called the change “unprecedented and short-sighted.”
Peter Graves, a spokesman for the Defense Health Agency, which oversees medical care and services for 9.6 million beneficiaries, including service members, military retirees and their families, said the Pentagon does not participate in contract negotiations between its pharmacy benefit managers and retail pharmacies. .
But, he said in an emailed statement, the changes won’t inconvenience many people in the program. Roughly 95% of beneficiaries will have access to at least two network pharmacies within a 15-minute drive, he said, and “99.8%” will have access within 30 minutes.
“Tricare will continue to meet or exceed Tricare’s standards for retail network pharmacy access,” Graves said. “Beneficiaries will continue to have many convenient, local in-network options to fill their medications, including beneficiaries in rural locations.”
In a separate email, Express Scripts spokesman Justin Sessions said the decision to leave the network “depends on pharmacies and/or wholesalers who negotiate on their behalf.” He added that about 80% of pharmacies dropped from the network had fewer than 50 prescription claims from Tricare in the past six months, and 25% had none. Sessions said Express Scripts has a team dedicated to contacting “the small percentage of beneficiaries who may be affected by these changes” and helping them move their prescriptions.
“Our responsibility is to ensure that Tricare beneficiaries can access their prescription drugs safely, affordably and conveniently, and at the best value for the Department of Defense and taxpayers,” Sessions said.
According to pharmacists, the transition is especially problematic for a small group of Tricare beneficiaries who are chronically ill, have a disability and receive home infusion medications.
Logan Davis, vice president of trade for VitalCare Infusion Services, which serves customers in 30 states, said the company’s services are covered by Tricare medical facilities, but the drugs used for infusions are often purchased from independent pharmacies.
The move could delay care for patients with chronic conditions such as rheumatoid arthritis, myasthenia gravis and Crohn’s disease, Davis said. Swapping intravenous prescriptions isn’t easy, he said.
“It may not be a large number of patients, but these are complex medication patients who are very sick who depend on these medications to stay out of the hospital and achieve quality of life,” Davis said.
Some lawmakers and advocacy groups condemned the move. Sen. Tom Cotton (R-Ark.), Rep. Buddy Carter (R-Ga.), and 98 members of Congress, both Republicans and Democrats, sent a letter to Acting Assistant Secretary of Health Celine Mullen on Sept. 29. The Defense Department protested the decision. They said the move could affect the health of beneficiaries and lead to higher administrative fees for the Defense Health Agency.
“Why did Express Scripts give DHA early termination of the 2022 contract?” they asked. “This will only further reduce the pharmacy network for Tricare patients and their families, and may force beneficiaries to change pharmacies at a time when many receive annual vaccinations.”
Carter’s website now has a form asking for feedback from affected patients, pharmacists and health care providers so lawmakers can catalog them and pressure the Biden administration to reverse. “We have been told by the Biden administration that they do not believe patients and pharmacists care about this loss of access,” the website said. “We know you do and we’re bringing your stories to them.”
Sessions, with Express Scripts, did not give a reason for accelerating the pharmacies’ exit from the network but said the pharmacies may have been blindsided because “obviously some wholesalers declined on behalf of their pharmacies without contacting them.”
The National Home Infusion Association reached out to Humana Military and Health Net Federal Services, the private company that provides medical care and services in the Tricare network, to get approval to provide the service but was told that Express Scripts, as the pharmacy arm of the process, transfers patients to an in-network provider. or refer them to a physician’s office for treatment.
“This is not an acceptable answer for a disabled veteran,” said Connie Sullivan, CEO of the National Home Infusion Association. “They usually get our services because they don’t have a provider who can do an infusion without spending hours getting there Transportation is very challenging.”
The National Community Pharmacists Association sent a letter Oct. 18 to Defense Secretary Lloyd Austin asking them to allow pharmacies to remain in the network through 2023 under the same conditions as this year.
“With most independent pharmacies outside the network, it is difficult to see how Cigna/Express Scripts is meeting even the lower access standards in its new contract with the DoD,” said the group’s CEO, B. Douglas Howe notes that Tricare’s value is that 90% of patients have at least one network pharmacy within a 15-minute drive.
“Without this action, access to essential drugs for Tricare beneficiaries is in jeopardy,” he said.
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