Doris Spatz takes a Kisqali pill once a day to control her metastatic breast cancer. As a patient in the Department of Defense Health System, she can fill routine prescriptions at a military pharmacy without copay, 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 her neighborhood in Alexandria, Virginia, and received life-saving medication there.
That is until Oct. 24, when Express Scripts, the pharmacy benefit manager for Tricare, dropped nearly 15,000 pharmacies from its network. Many were small independent pharmacies, such as Neighborhood Pharmacy of Del Ray, where Spatz was a customer.
This decision created problems, according to Doris’ husband, Dr. Michael Spatz, because the breast cancer drug is not available at every pharmacy. And some larger chains require patients to use a branch of their business known as a specialty pharmacy for expensive or scarce drugs for complex conditions.
“Express Scripts told us, ‘You can just go to CVS,'” Michael Spatz said. “But it was kind of a mess because you can’t just go to CVS and get a drug for $1,500. You have to be in their special pharmacy system.”
About 27 percent of all pharmacies in the Tricare network are no longer covered, leaving more than 400,000 military beneficiaries affected. The move has upset customers and many independent pharmacies and raised concerns among some military advocates and lawmakers, particularly those in rural states who believe it disproportionately affects rural veterans.
In a September letter to the Department of Defense, U.S. Sen. John Tester (D-Mont.), chairman of the Senate Veterans Affairs Committee, said: “I can no longer rely on my local pharmacy for access to necessary medications and in-person consultations with a pharmacist , they will be forced to drive long distances to find pharmacies in the corporate network or be directed to the Express Scripts mail delivery program. This is unacceptable.”
Many of the affected pharmacies knew they would be out of network at the end of the year because they did not accept Express Scripts’ terms, which included reduced reimbursement rates. But they were surprised by the early ejection, said Rona Houser, senior vice president of policy and pharmaceutical affairs at the National Association of Community Pharmacists. “It was a very botched implementation of this new network and unfortunate, ultimately, for the patients,” she said.
The Military Officers Association of America, an advocacy group for active and retired personnel, said it was pushing for the decision to be overturned.
While acknowledging that the Defense Department is under pressure to control health care spending, Karen Ruedisweli, the association’s director of government relations for health, called the change “unprecedented and short-sighted.”
Peter Graves, a spokesman for the Defense Health Care Agency, which oversees medical care and services for 9.6 million beneficiaries, including service members, military retirees and their families, said the Pentagon is not involved in contract negotiations between its pharmacy manager and the pharmacies retail .
But, he said in an emailed statement, the changes won’t inconvenience many of the people in the program. About 95 percent of beneficiaries will have access to at least two network pharmacies within a 15-minute drive, he said, and “99.8 percent” will have access within 30 minutes.
“Tricare’s retail network will continue to meet or exceed Tricare’s pharmacy access standard,” Graves said. “Beneficiaries will continue to have many convenient, local in-network options to fill their medications, including those beneficiaries in rural areas.”
In a separate email, Express Scripts spokesman Justin Sessions said the decision to leave the network is up to “the pharmacy and/or wholesalers negotiating on their behalf.” She added that roughly 80 percent of pharmacies that were out of network had fewer than 50 prescription requests in the past six months from Tricare, and that 25 percent had none. Sessions said Express Scripts has a team dedicated to reaching out to the “small percentage of beneficiaries who may be affected by these changes” and helping them move their prescriptions.
“It is our duty to ensure that Tricare beneficiaries have access to their prescription drugs safely, affordably and conveniently, and at the best cost to the Department of Defense and taxpayers,” Sessions said.
The transition is particularly problematic for a small group of Tricare beneficiaries who are chronically ill, have disabilities and receive infused drugs in their homes, according to pharmacists.
Logan Davis, vice president of sales at Vital Care Infusion Services, which serves customers in 30 states, said the company’s services are covered by Tricare medical benefits, but that 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 IV prescriptions isn’t easy, he said.
“It may not be a huge number of patients, but these are patients on complex medications who are very sick, who depend on getting these medications to stay out of the hospital and have a 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, Republicans and Democrats, sent a letter Sept. 29 to Seileen Mullen, acting assistant secretary for health at the Department of Defense, protesting the decision. They said the move could affect the health of beneficiaries and lead to higher administrative costs for the Defense Health Agency.
“What reasons did Express Scripts give DHA for early termination of the 2022 contracts?” they asked. “This will only further reduce the pharmacy network for Tricare patients and their families, and may force beneficiaries to switch pharmacies at a time when many are receiving annual vaccinations.”
Carter’s website now includes a form asking for feedback from affected patients, pharmacists and health care providers so the lawmaker can catalog it and pressure the Biden administration for a repeal. “We have been told by the Biden administration that they do not believe patients and pharmacists care about losing this access,” the website said. “We know you do, and we’re providing them with your stories.”
Sessions, with Express Scripts, did not give a reason for speeding up the pharmacies’ exit from the network, but said the pharmacies may have been blindsided because “apparently some wholesalers dropped their pharmacy names without telling them.” .
The National Home Infusion Association approached Humana Military and Health Net Federal Services, the private companies that provide medical care and services to the Tricare network, for permission to provide services, but was told that Express Scripts, as the pharmacy arm of process, will attempt to transfer patients to a network provider or send them to a doctor’s office for their treatment.
“This is not an acceptable response 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 Association of Community Pharmacists sent a letter Oct. 18 to Defense Secretary Lloyd Austin urging him to allow pharmacies to remain in the network through 2023 under the same conditions as this year.
“Since the majority of independent pharmacies are out-of-network, it is difficult to see how Cigna/Express Scripts meets even the reduced access standards in its new contract with the Department of Defense,” wrote the group’s CEO, B. Douglas Howie, citing Tricare’s standard is that 90% of patients have at least one network pharmacy within a 15-minute drive.
“Without this action, access to needed drugs for Tricare beneficiaries is in jeopardy,” he said.
This article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health policy research organization not affiliated with Kaiser Permanente.