Troops may face inflated drug costs under Tricare, lawmakers say

A bipartisan group of 24 congressional lawmakers is questioning whether or not the Pentagon’s pharmacy contract could also be driving up drug prices and limiting entry to treatment for Tricare beneficiaries, whereas overcharging unbiased pharmacies and taxpayers.

The lawmakers are involved that the Protection Well being Company has determined to retain Specific Scripts as the only real pharmacy profit supervisor for Tricare, the navy insurance coverage system serving 9.6 million troops, retirees and their households.

In a letter despatched Wednesday to Assistant Secretary of Protection for Well being Affairs Lester Martinez-Lopez and DHA director Military Lt. Gen. Telita Crosland, the lawmakers questioned whether or not Specific Scripts could also be utilizing anticompetitive ways to overcharge Tricare.

Specific Scripts is the second-largest pharmacy profit supervisor within the nation. PBMs act as middlemen for pharmacies, drug firms and insurers and play a key position in negotiating drug costs between the varied gamers, in addition to serving to to resolve which medicines an insurer will cowl.

Critics argue PBMs’ typically secretive work has pressured scores of Individuals to overspend on treatment or stored them from having the ability to entry the medication they want. PBM proponents argue they in the end drive down prices within the medical system and make sure the prescription drug enterprise runs easily.

The letter, led by Sen. Elizabeth Warren, D-Mass., Sen. Mike Rounds, R-S.D., Sen. Peter Welch, D-Vt., and Rep. Buddy Carter, R-Ga., calls for solutions by July 2 from protection officers on how they monitor the Specific Scripts contract, how strong the pharmacy community is, and whether or not DHA tracks Specific Scripts’ denials for costly specialty medicine requested by Tricare beneficiaries. Twenty extra members of Congress signed onto the letter.

At situation is the slender set of firms via which troops and their households obtain drugs underneath Tricare well being plans.

Tricare members can acquire pharmaceuticals via two entities: Specific Scripts, which handles nonspecialty treatment, or Accredo, which handles specialty medicine for situations like most cancers and a number of sclerosis. Accredo has served as Tricare’s main in-network specialty pharmacy for the reason that starting of 2023, although sufferers should purchase specialty medicine via different pharmacies as properly.

Each firms are Cigna subsidiaries. Lawmakers fear the association makes Tricare clients susceptible to increased drug costs, and will in the end drive up the associated fee to taxpayers who cowl government-provided medical health insurance.

“As a result of Cigna additionally owns Accredo, it could actually successfully preserve a lot of its enterprise in-house, utilizing its [pharmacy benefit manager Express Scripts] to steer sufferers to its personal pharmacy whereas disadvantaging rivals,” the lawmakers wrote.

Lawmakers wish to know whether or not DHA has in contrast the costs Specific Scripts expenses for specialty medicine via Accredo versus what it expenses for a similar medicine at unbiased pharmacies. In addition they ask how a lot Specific Scripts expenses for every of the ten most steadily prescribed merchandise bought via Accredo, and the way a lot it expenses for a similar prescriptions when they’re bought via unbiased pharmacies.

In an announcement supplied to Navy Occasions, Specific Scripts officers mentioned Tricare beneficiaries aren’t required to fill nearly all of specialty prescriptions via Accredo, “although many select to due to the extremely customized assist they obtain from their pharmacists, nurses, clinicians, dietitians and social employees.”

Firm officers mentioned they supply Tricare beneficiaries “with top quality, inexpensive well being care whereas attaining billions of {dollars} in financial savings for the federal government and taxpayers. Tricare beneficiaries have entry to the complete vary of generic, model, and specialty drugs in the marketplace right this moment via our strong community of chain, unbiased, navy, specialty and residential supply pharmacies.”

Tricare members have fewer unbiased and retail pharmacies to depend on than they did a number of years in the past. In 2022, 15,000 pharmacies left the Tricare community whereas refusing to just accept the contract’s phrases for reimbursement from Specific Scripts. After public strain, Specific Scripts reopened its community, however fewer than 5,000 pharmacies rejoined.

“This exodus of unbiased and retail pharmacies could be catastrophic for Tricare beneficiaries, particularly for these with complicated medical situations who’re ill-served by mail-order pharmacies,” the lawmakers wrote.

There are presently greater than 42,000 pharmacies, together with almost 12,000 unbiased pharmacies within the Tricare community. Ninety-eight p.c of beneficiaries have a Tricare retail pharmacy inside a 15-minute drive.

Lawmakers ask how the Protection Well being Company verifies that Specific Scripts obeys affected person entry necessities, together with that no less than one in-network pharmacy is positioned inside a 15-minute drive of 90% of Tricare beneficiaries.

They famous that the Protection Well being Company can revise the phrases of the contract or go away the unique settlement with Specific Scripts annually till the contract ends in December 2029.

A DHA spokesperson on Friday declined to touch upon the letter: “It isn’t acceptable for us to touch upon questions till now we have responded formally to the members of Congress.”

The company has beforehand informed Navy Occasions that the contract permits Specific Scripts to make use of its personal discretion in contracting with pharmacies to determine a competitively priced community that meets contract entry requirements, immediately passing financial savings to the federal government.