Evolution of the TRICARE Pharmacy Benefit: A Decade of Change.

TRICARE is the military's health plan that provides coverage to 9.4 million active duty and retired uniformed services personnel and their family members. The TRICARE pharmacy benefit has undergone many changes in the last decade. These changes include assigning newly approved drugs to nonformulary status after regulatory approval, the addition of weight loss medications to the benefit, channel management point-of-service requirements for some medications, and copay increases. Several initiatives have resulted in significant cost avoidance to the Department of Defense (DoD). The purpose of this article is to discuss the changes to the TRICARE pharmacy benefit, describe the continual challenges, and estimate cost savings associated with implementation of these changes. DoD implemented its 3-tier Uniform Formulary in 2005. Since then, many changes have been enacted, including more extensive use of prior authorization, step therapy, and quantity limits; coverage of over-the-counter medications; the retail refund program; coverage of vaccines and smoking cessation agents; mandatory mail/military treatment facility requirements; rapid review and initial nonformulary status for newly approved innovator drugs; revisions to the compounded drug benefit; initial deployment of a new medical record system; coverage of weight loss medications; and the ability to exclude medications from the Uniform Formulary. Although the TRICARE pharmacy benefit has evolved significantly, the focus remains on the beneficiaries, with an overall goal of providing integrated, affordable, and high quality health services for the Military Health System. Challenges for the future include maximizing clinical effectiveness in the face of rising pharmaceutical costs and cost avoidance, while supporting the needs of TRICARE beneficiaries. DISCLOSURES: No outside funding supported this study. The authors declare no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria. The information discussed here represents the views of the authors and does not necessarily reflect the views of the Defense Health Agency (DHA), the Department of Defense (DoD), or the Departments of the Army, Navy, and Air Force. The authors have nothing to disclose that presents a potential conflict of interest.

Automated profile review for transdermal fentanyl to verify opioid tolerance in the military health system.

OBJECTIVE: Describe a patient safety program designed to decrease use of transdermal fentanyl (TF) among opioid-naïve patients in the U.S. Military Health System (MHS). METHODS: The program automatically reviewed patient profiles for prior strong opioid use when starting treatment with TF. New prescriptions for TF among users without a prior strong opioid generated a rejection message indicating that the patient may not be opioid tolerant and stopped the fill. However, pharmacists could override the rejection. We collected pharmacy claims data to measure the use of TF among seemingly opioid-naïve patients following implementation of the program in August 2007. RESULTS: During the first 10 months, 26,366 patients attempted to fill TF prescriptions in the MHS; 10,025 patients (38%) encountered a claim rejection, with a warning message advising the pharmacist to verify opioid tolerance. The majority of rejection messages were overridden by the pharmacist; however, 1,402 patients did not receive a TF prescription following the rejection, representing a 14% decrease in TF claims dispensed to patients who appeared opioid naïve in the MHS. CONCLUSION: A patient safety program with targeted pharmacy messaging reduced TF use among seemingly opioid-naïve patients in the MHS without disrupting treatment for patients whose rejections were overridden.

Results from a mailed promotion of medication reviews among Department of Defense beneficiaries receiving 10 or more chronic medications.

BACKGROUND: Like many payers, the Department of Defense (DoD) has limited ability to work directly with prescribers to ensure appropriate medication use. Many older beneficiaries are prescribed multiple maintenance medications, placing them at higher risk for adverse drug interactions, contraindicated medication use, and other polypharmacy-related problems. Medication reviews may mitigate these risks, but the optimal venue for medication therapy management is unclear. OBJECTIVES: To (a) determine if beneficiaries will respond to a mailed request from the DoD to pursue a medication review; (b) identify medication review location and outcomes from the patient perspective; and (c) assess the statistical significance of changes in the number of prescription medications overall and for key categories, including maintenance medications and contraindicated medications, relative to a propensity-matched comparison group. METHODS: A total of 4,000 TRICARE beneficiaries aged 55 years or older, residing in North Carolina, who obtained 10 or more maintenance medications (defined by a unique combination of drug, strength, and dosage form) during the 90-day baseline period from May 3, 2008, to July 31, 2008, were mailed letters requesting their participation in the study. Consenting subjects received a personalized medication list to review with their physicians or pharmacists and a survey form to complete after the review. Survey results were compared by location of medication review (i.e., physician's office, pharmacy, or both). Changes from the 90-day baseline to 90-day post-intervention period were calculated for prescription utilization measures (total drug count, maintenance drug count, count of Beers list medications, and count of contraindicated drug combinations) for the subsample of subjects who completed the survey (n = 373) and for subjects who received the initial consent letter (n = 3,856) versus a propensity-matched comparison sample drawn from neighboring states. Variables included in the propensity score were gender, age group, military rank, catchment status indicating proximity to military pharmacies, enrollment status, number of pharmacy settings used, and each of 30 binary disease indicators. RESULTS: A total of 1,469 subjects responded to the consent letter (response rate = 38.1%); 606 subjects consented to participate (consent rate = 15.7%); and 373 subjects returned a completed survey (completion rate = 9.7%). Among those who completed the survey, 190 (50.9%) received reviews in a physician's office; 103 (27.6%) received reviews in a pharmacy; 60 (16.1%) received reviews in both locations; and 20 (5.4%) reported a different location or no location. 61 survey respondents (16.4%) indicated that they were told to stop a medication, and 77 (20.6%) reported a dosage change. Medication changes occurred significantly more frequently for reviews performed at a physician's office compared with other review locations. Therapeutic classes most frequently stopped or adjusted for dosage were antidiabetics, diuretics, antilipidemics, renin-angiotensin aldosterone system inhibitors, anticoagulants, nonsteroidal anti-inflammatory drugs, and beta-adrenergic blocking agents. 85% of respondents reported that the medication review was worth doing. In the assessments of changes in prescription utilization from the baseline to post-intervention periods, no significant by-group differences were noted among those who completed the study relative to their matched comparison subjects. In the comparison of subjects who received the initial consent letter with their matched counterparts, small but statistically significant differences were observed for several prescription utilization measures, including changes in use of high-risk Beers list medications (P = 0.033); use of electrolytic, caloric, and water balance medications (P = 0.038); and use of hypertension medications (P = 0.028). The magnitude of the decrease observed among comparison subjects, however, exceeded that observed among the case subjects. CONCLUSIONS: Response was poor to a mailing that promoted a beneficiary- initiated medication review. The absence of significant changes following the medication review suggests several possibilities: a mailed intervention is ineffective in promoting medication review; medication regimens for study subjects are already optimized to the extent obtainable through a routine medication review; or the study sample size was too small to detect relevant changes. Most drug regimen changes were dosage adjustments for current medications or substitutions within the same therapeutic class. The extent to which comprehensive assessment of a patient's medication regimen, including nonprescription and herbal agents, was performed is unclear. More intensive interventions may be required to ensure that medication regimens are being actively managed among those who use a large number of prescription medications.

Trends in prescription drug utilization and spending for the Department of Defense, 2002-2007.

OBJECTIVE: Examine trends in U.S. Department of Defense (DoD) outpatient drug spending and utilization between 2002 and 2007. METHODS: We analyzed pharmacy claims data from the U.S. Military Health System (MHS), using a cross-sectional analysis at the prescription and patient-year level and measuring utilization in 30-day equivalent prescriptions and expenditures in dollars. RESULTS: Pharmaceutical spending more than doubled in DoD, from $3 billion in FY02 to $6.5 billion in FY07. The largest increase occurred in the DoD community pharmacy network, where utilization grew from 6 million 30-day equivalent prescriptions in the first quarter of FY02 to more than 16 million in the last quarter of FY07. The smallest increase in annual spending occurred in FY07 (5.5%), down from a high of 27.5% in FY03. CONCLUSIONS: The MHS has experienced rapid growth in pharmaceutical spending since FY02. However, there are signs that growth in pharmaceutical spending may be slowing.

Increase in lipid-lowering treatment rates among TRICARE beneficiaries: a population-based study.

PURPOSE: To evaluate the use of lipid-lowering treatment (LLT) among patients at risk for cardiovascular disease (CVD) in the US Military Health System (MHS). METHODS: The study examined healthcare service and prescription records among beneficiaries > or =18 years for calendar years 2002, 2004, and 2006. Patients were categorized based on cardiovascular (CV) risk, with exposure to LLT defined as one or more prescriptions for lipid-lowering medication. Logistic regression models estimated odds of treatment in 2004 and 2006 relative to 2002 after adjustment for age, gender, and CV risk. RESULTS: The yearly unadjusted population prevalence of LLT increased from 9.3% in 2002 to 14.7% in 2006. Among subjects with the highest CV risk, established coronary artery disease (CAD) or peripheral vascular disease (PVD), those receiving LLT increased from 55% in 2002 to 65% in 2006 (adjusted OR = 1.50, 95% CI 1.48, 1.52, p < 0.00). Treatment rates among diabetic patients with no coded CAD or PVD showed the largest relative increase from 47% in 2002 to 66% in 2006 (adjusted OR = 2.30, 95% CI 2.26, 2.332, p < 0.00). LLT growth was lowest among those with only 1 coded CV risk factor (adjusted OR = 1.32, 95% CI 1.31, 1.34, p < 0.00). CONCLUSIONS: The MHS experienced a significant increase in LLT among patients at greatest risk for cardiovascular disease. However, treatment may still be underutilized as approximately one-third of high-risk patients did not receive lipid-lowering medication.

Formulary management in the Department of Defense.

BACKGROUND: The U.S. Department of Defense (DoD) health care benefit (TRICARE) provides 9.2 million active-duty and retired uniformed services personnel and their family members with access to a comprehensive pharmacy benefit with low out-of-pocket costs. DoD's Uniform Formulary is available worldwide at DoD's 3 pharmacy points of service (military pharmacies, contracted mail order, and community [network and non-network] pharmacies). Community pharmacies, military pharmacies, and mail order accounted for 64%, 23%, and 13%, respectively, of DoD's $6.5 billion total drug expenditures during fiscal year (FY) 2007 (October 1, 2006, through September 30, 2007). OBJECTIVE: To describe the DoD formulary management process and estimate cost savings associated with implementation of DoD's 3-tier formulary. SUMMARY: DoD implemented its 3-tier Uniform Formulary in 2005. This implementation required the development of a transparent formulary management process that (a) assesses medications for formulary status based on an evidence-based clinical evaluation and assessment of relative cost-effectiveness using pharmacoeconomic and budget impact modeling, (b) allows open and equitable price competition among pharmaceutical manufacturers based on formulary status, and (c) provides a public forum for beneficiaries and beneficiary organizations to comment on formulary changes. Through April 16, 2008, Uniform Formulary decisions had been implemented in 32 drug classes representing 53% of FY 2007 total drug expenditures. The 32 classes containing 343 drugs were reviewed at 12 quarterly meetings of the DoD Pharmacy and Therapeutics (P&T) Committee and the Beneficiary Advisory Panel, resulting in the classification of 85 drugs (24.8%) in tier 3, 92 drugs (26.8%) in tier 2, and 166 drugs (48.4%) in tier 1. Implementation of the 3-tier formulary was associated with an estimated $926 million in cost avoidance in FY 2007, primarily due to price reductions at military pharmacies and mail order, tier 3 copayments at community pharmacies and mail order, and change in product mix and pharmacy type (point of service). An additional $60 million in rebates were obtained in FY 2007 through the Voluntary Agreements for TRICARE Retail Pharmacy Refunds (UF VARR) program for prescriptions filled at community pharmacies; the UF VARR program first became available for drug classes reviewed in August 2006. The total of $986 million in cost avoidance and rebates represents an approximate 13% reduction, compared with what DoD otherwise would have paid in FY 2007 ($7.5 billion, compared with actual drug expenditures of $6.5 billion). CONCLUSION: As in most private-sector health plans, the DoD formulary management process (a) includes rigorous decision making that is informed by clinical literature evaluations and pharmacoeconomic analyses, (b) results in drug formulary changes that require considerable effort in communication with providers and beneficiaries, and (c) produces drug cost savings derived from increased price competition among drug manufacturers. Unlike private sector health plans, the DoD uses more disclosure of the results of evaluation of the evidence, solicits provider opinions before P&T committee deliberation, and provides the opportunity for beneficiaries to have input before implementation of formulary changes.