Tricare Pharmacy Contract Uncertainty Causes Congress to Push for Answers
U.S. lawmakers are seeking answers on an apparent about-face by Tricare's pharmacy benefits manager to let thousands of independent pharmacies rejoin the Tricare network after they were ousted last month.
Earlier this month, Express Scripts began notifying thousands of independent and community pharmacies that they have a chance to rejoin the network under new contract offers that would be effective Jan. 15. But the company has not made clear whether the terms would be the same as those offered and rejected earlier this year by many of the 14,963 pharmacies that were told they were no longer in the network beginning Oct. 24.
And that has members of the House and Senate, including the top Republican on the House Armed Services Committee, questioning the terms of the new contract that will be offered to the pharmacies. On Monday, 49 members -- 48 Republicans and one Democrat -- sent a letter to the Defense Health Agency asking for details. "Even though we understand that Express Scripts is offering these pharmacies the opportunity to rejoin the network, if the contract terms remain the same as the first offer, pharmacies will likely be forced to remain out of network," wrote Rep. Buddy Carter, a Georgia Republican and pharmacist; Rep. Mike Rogers, R-Ala., the ranking member of the Armed Services Committee; and others.
"DHA's decision has come at the expense of small businesses, independent community pharmacies, specialty pharmacies, long-term pharmacies and, most importantly, the beneficiaries they serve," they wrote.
The letter comes as more patients and institutions learn the impact of the changes on their prescriptions and pharmacies.
According to the letter, children's hospitals have started raising concerns about their ability to discharge pediatric patients without assurances that families will have immediate access to the medications their children need once they are home.
Also vulnerable are chronically ill or disabled Tricare beneficiaries who receive infusion medications in their homes, according to the association that represents companies that provide such services. While infusion care is covered under Tricare's medical benefit, the medications used for infusions often are purchased from independent pharmacies, many of which were dropped as a result of the change in contract terms.
This affects a small group of Tricare beneficiaries who are chronically ill, have a disability, and receive infusion medications in their homes, according to the National Home Infusion Association.
"We are a smaller subset of patients that often is the most vulnerable and sickest. ... IV drugs just take much more coordination and oversight by the pharmacist and the nurse and the physician," said Connie Sullivan, the association's president and CEO, in an interview. Tricare beneficiaries in long-term care facilities also are seeing the fallout, according to Alan Rosenbloom, CEO of the Senior Care Pharmacy Coalition.
In an email, Rosenbloom said the terms of the contract offered in July by Express Scripts would have caused most long-term care pharmacies to lose money, with some saying that if they had agreed to the contract, they would have gone "from roughly break-even on Tricare to losing about $15 per prescription."
With the average number of prescriptions per person in long-term care being roughly a dozen medications, the cost adds up, he explained.
"The law requires long-term care pharmacies to provide an array of specialized and clinical services, which translates into higher costs. Most payers recognize these costs by paying long-term care pharmacies more than retail or mail order pharmacies. [Express Scripts] does not recognize these legal obligations and related higher costs," Rosenbloom said.
Express Scripts dropped the independent pharmacies from the network effective Oct. 24. While many had declined to renew their contracts due to reduced reimbursement rates in the new contracts, they were blindsided by the Oct. 24 dismissals, believing they would stay on the network until the end of the year.
Some of the affected pharmacies said they never received information on the new contracts because their wholesaler or agencies that represent them in negotiations had declined the contract on their behalf.
The grocery store chain Kroger announced it planned to leave the Tricare network as a result of the contract negotiations, a decision that prompted Express Scripts to re-offer contracts to community and independent pharmacies, according to the company.
Carter; Sen. Tom Cotton, R-Ark.; and 97 lawmakers sent a letter in September to Seileen Mullen, acting assistant secretary for health affairs at the Defense Department, protesting the decision by Express Scripts to drop the community pharmacies.
A spokesman for Carter said the congressman never received a response.
Express Scripts officials told Military.com, however, that they believe some pharmacies will return to the network, and they pointed to feedback from lawmakers as one of the reasons they are re-offering the contracts.
Neither Express Scripts nor the Defense Health Agency responded to a request for comment on the most recent congressional letter by publication.
About the Author: Patricia Kime can be reached at Patricia.Kime@Military.com. Follow her on Twitter @patriciakime. -- Military.com reporter Rebecca Kheel contributed to this report.
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