Every few weeks, Tricare For Life beneficiary Patricia Petteruti receives a letter from Tricare pharmacy benefits manager Express Scripts.
She’s supposed to get her prescription drugs in the mail, too. But instead, these letters inform her that her medications — common prescriptions for a heart condition and hypotension — are out of stock.
Like all TFL beneficiaries — and, as of Oct. 1, any Tricare beneficiary taking a brand-name medication to manage a chronic illness — Petteruti is required to fill long-term prescriptions through Tricare’s home delivery program or an on-base military pharmacy.
Since she lives 50 miles from the nearest base, she has opted for mail order. But since February, the system has been anything but user-friendly.
“Recently, I got two letters dated Sept. 11, 2015,” she said. “One said: ‘We are unable to dispense your prescription … temporarily unavailable.’ The other one: ‘This letter is to inform you that your medication is now in stock.’ What am I supposed to make of this?”
Retired Air Force Lt. Col. Howard Durant also tries to use the home delivery program. But earlier this year, his generic medications stopped coming.
He can fill the prescriptions at a Tricare network pharmacy, but unlike mail order, which provides 90-day generic prescriptions for no co-payment, the drug store dispenses 30-day prescriptions for a co-payment of $8.
For his three medications, that’s $24 a month and $288 per year for a benefit that the Defense Department says Durant must use.
“I’m doing everything I’m supposed to be doing to keep costs down, for myself and the government,” Durant said. “I’m using generics and I’m using mail order. But it’s just not working. Sure seems like Express Scripts has found a way to get out of filling prescriptions.”
Tricare officials say the problem stems from drug shortages that are an “increasing problem across the industry.”
And the shortages are exacerbated within the military system because by law, DoD is allowed to buy pharmaceuticals only from certain manufacturers, according to Tricare pharmacy director Dr. George Jones.
“The Drug Information Service at the University of Utah found a dramatic increase in drug shortages over the last five years, peaking in 2014,” Jones said.
Shortages have begun to decline amid concerted efforts by government, manufacturers and the pharmacy industry, he said, but remain “high compared to historic levels.”
The shortages peaked at about the time DoD began requiring Medicare-eligible retirees and military family members to fill their long-term prescriptions by mail or at a military pharmacy.
On Oct. 1, all Tricare beneficiaries using brand-name medications for chronic conditions were also required to start filling their prescriptions the same way.
The program is designed to save money; DoD pays 17 percent less for maintenance medications filled by mail than at retail stores.
Savings over the first year of the Tricare For Life pilot program totaled $123 million, according to a recent Government Accountability Office report.
Tricare beneficiaries filled 25 million prescriptions by mail from February 2014 to February 2015, including 785,000 for TFL beneficiaries newly required by law to use the home delivery program.
During the first year of that TFL requirement, 5,069 patients — three percent of participants — received a total of 5,611 letters notifying them of shortages and authorizing them to fill their prescriptions at retail pharmacies, the GAO said.
That meant shortages “affected less than one percent of home delivery prescriptions … comparable to the home delivery program at large,” Jones said.
And according to a 2013 DoD Inspector General report, 96 percent of Tricare beneficiaries “are satisfied with home delivery and it has a 99.997 percent dispensing accuracy rate.”
But DoD also noted that only 1,448 of the 5,611 exceptions granted due to shortages were actually filled at a retail store.
Possible explanations for that low usage rate, defense officials said, could include doctors changing their patients’ medications to an available drug, beneficiaries filling their prescriptions at a military pharmacy or beneficiaries simply choosing not to fill them because of the higher co-payment.
But GAO Health Care Director Debra Draper pointed out that, since Tricare did not specifically track the satisfaction of beneficiaries now required to use the mail-order system and did not monitor the availability of covered medications for these beneficiaries, DoD is “unable to assess availability.”
“DoD does not know what, if any problems, beneficiaries may have experienced filling their prescriptions,” Draper concluded in her report.
With the new requirement for all Tricare beneficiaries to get their non-generic maintenance medications by mail — an estimated 416,000 beneficiaries new to the system — current users fear their problems will worsen.
“These are very common drugs, and I suspect a substantial portion of retirees take them,” Durant said of his medications, taken for for angina and high blood pressure.
He said he would like to see Tricare be allowed to expand its list of approved vendors or reimburse beneficiaries for pharmacy co-payments.
DoD officials say they are restricted to purchasing through designated sources by the Trade Agreements Act of 1979 and simply can’t reimburse for pharmacy co-pays.
“If a beneficiary chooses to use a retail pharmacy, DoD regulations do not allow [Express Scripts or the Defense Health Agency] to waive co-pays,” Jones said.
Express Scripts declined to answer questions on the problem and “deferred to the Defense Health Agency” for response.
Petteruti, a retired nurse, said she wants the problem resolved quickly, before retirees without easy access to a pharmacy go without their medications or, worse, skip or double-up doses out of confusion related to erratic deliveries or store purchases.
Durant said the issue is not about having to pay more money for his medications, but rather about ensuring that a program now mandatory for many Tricare beneficiaries actually works as intended.
“It’s a privilege to have these pharmacy benefits,” he said. “I’m just irritated with the bureaucracy.”
