Military families and retirees who regularly refill some brand-name medications at retail pharmacies will need to either switch to home delivery, get their drugs at a military treatment facility or start paying for them out of pocket beginning Oct. 1.
Right now, Tricare subsidizes all covered brand-name medication at in-network, civilian retail pharmacies. Users pay $20 for a 30 day supply, while Tricare covers the remaining cost. But the new rule will force users who buy "maintenance" drugs at those locations to pay the entire cost out pocket.
The change only impacts prescription drug refills considered "maintenance" medications by Tricare because they are refilled and taken regularly to treat chronic health problems like high cholesterol, allergies or anxiety. Brand-name drugs filled for any other reason, like short-term pain or antibiotics, will still be covered at the current rate. Users will also be able to fill at a retail pharmacy an initial 30-day supply of a new maintenance drug before switching to the mail order or MTF systems, officials said.
Mail-order brand-name drugs will continue to cost users $16 for a 90-day supply. All drugs filled at a military treatment facility (MTF) will continue to be free.
Users affected by the policy change will receive a notice by mail in mid-September with instructions on how to change their pharmacy to mail-order or an MTF. A complete list of brand-name maintenance drugs affected by the change can be viewed here.
Users will get several chances to refill their medication after Oct. 1 at their retail pharmacy before being forced to pay out of pocket. Tricare will pay its previous portion of the first two refills of any given maintenance drug, but payment of the third refill will be blocked, according to an interim coverage rule.
The new rule will not impact active-duty users, beneficiaries stationed overseas or nursing home residents, officials said. Tricare users can also receive a waiver on a case-by-case basis.
It will also not change the cost of generic drug purchases, regardless of what condition the drug is treating. Those will continue to cost $8 for a 30-day supply at retail pharmacies.
The change comes on the heels of a 2014 pilot program that tested the change among Tricare for Life users, who are over 65-years-old and use Tricare in tandem with Medicare. Officials expect the change to save the Defense Department $85 million per year, because filling brand name drugs through pharmacy contractor Express Scripts, which manages the mail order program, or at a military pharmacy costs less.
The change will also force savings upon Tricare users. Officials estimate users will annually save about $16.5 million, or about $176 per drug.
--Amy Bushatz can be reached at firstname.lastname@example.org.