According to recent coverage by MOAA, Tricare will soon be dropping thousands of prescriptions from coverage at MTFs and by mail. You’ll still be able to get the medications you need – just from a retail pharmacy and at full cost.
Will Tricare Still Cover Your Prescriptions?
These most recent changes follow on the heels of a shift started in fiscal year 2018. During the National Defense Authorization Act, the Defense Health Agency was authorized to move certain types of drugs to Tier 4, medications that are no longer covered in any way by Tricare. Their cost does not apply to the annual catastrophic cap either.
Tier 4 drugs are supposed to be limited to those that:
- Offer little to no benefit generally or relatively
- Are in danger of doing more harm than good
- Could be replaced by another drug
- Come at a higher cost than covered alternative medications
At first, this wasn’t a huge issue. The prescription medications impacted were used by relatively few beneficiaries, according to MOAA.
In August 2019, the first round of Tier 4 medications was announced. It included:
- Glumetza: an anti-diabetic medication
- Vimovo: used to treat various forms of arthritis
- Lexette: a psoriasis treatment
Relatively few of Tricare’s beneficiaries used these specific medications.
Widely Used Prescriptions Get Bumped to Tier 4
In November 2019, Dexilant, a GERD medication, was removed. This change impacted approximately 19,000 Tricare beneficiaries according to MOAA.
At the start of 2020, MOAA learned that Tricare and the DHA were considering moving Cialis and Viagra to the Tier 4 list. This decision was pending a final decision from the DHA director as of mid-January 2020.
A review panel voted 6-2 to remove the brand name medications from the formulary, or covered, drugs. Only the generic version of these drugs would remain available via Express Scripts or an MTF pharmacy.
This vote also determined that men over age 40 would not need prior authorization from their PCM to receive erectile dysfunction drugs. Men under age 40 or those with enlarged prostates would still need authorization.
In addition, this policy change would move other brand name and generic erectile dysfunction drugs to the Tier 4 list. Those could include:
- all associated generics of these brand names
From Covered to Non-Covered
When this new tier of medications was announced for fiscal year 2018, a process for consideration was also released.
New drugs could be considered for the move to Tier 4 quarterly on a limited basis. This allowed DHA to identify reasonable generic or formulary alternatives to replace the possibly non-covered medication.
The removal of a medication’s coverage status would take place over an extended period. This would allow patients to consult with their doctors about alternative treatments.
Express Scripts, the prescription mailing service used by Tricare, would also notify beneficiaries of their medication’s tier change 30-60 days before the final switch. At that time, patients would also be informed of next steps to take to ensure continued care.
MOAA’s Concern Over Tier 4 Drug Changes
While there are checks in place to prevent a large number of beneficiaries from feeling the impact of a drug’s change in status, MOAA is concerned that this might not be enough.
They cite the 19,000 patients impacted by Dexilant’s Tier 4 status change in November 2019. There are currently three other formulary alternatives available that are comparable to Dexilant, per a January 29, 2020 search of the Tricare formulary database.
In addition, MOAA is concerned that the panel has not followed the 2018 policy language with fidelity. They especially point to the phrase “provide very little to no clinical effectiveness.” MOAA does not seem to support the idea that the targeted erectile dysfunction medications or the GERD medication meet this standard for exclusion from the formulary.