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Insurance Issues

 

TRICARE

TRICARE is the health care program for almost 9.5 million beneficiaries worldwide—including active duty service members, National Guard and Reserve members, retirees, their families, survivors, certain former spouses and others registered in the Defense Enrollment Eligibility Reporting System (DEERS).

What is a Pharmacy Benefits Manager (PBM)?

A PBM essentially acts as a middleman, with either an employer or health plan on one side and pharmacies and drug manufacturers on the other. PBMs process pharmacy benefit claims and negotiate prescription drug prices with drug manufacturers. According to the Wall Street Journal, “they generally make money through service fees from large customer contracts for processing prescriptions, operating mail-order pharmacies, and negotiating with pharmacies and drug makers. Their contracts can include incentives for cutting costs.”1

1. Gryta, Thomas. What is a ‘Pharmacy Benefit Manager?’ Wall Street Journal. July 21, 2011.

About two years ago the Pharmacy Benefits Manager for Tricare, Express Scripts (ESI), tried to eliminate compounds from the list of accepted medications. Due in large part to those subscribed to ProtectMyCompounds and other groups, Tricare decided to take a wait and see approach.

At the heart of the matter was ESI’s inability to do their job and manage the drug spend. Compounds are an important part of therapeutics used to help our military get back to full fighting strength. ESI’s chose to blame the entire industry rather than implement a workable plan that would allow for compounds but also control the cost.

After many talks with Tricare, ProtectMyCompounds had made several suggestions to the DoD and Tricare, Tricare has implemented a screening process that would look for those compounds that were not priced accordingly.
The new process should really help to reduce cost and still allow for our active and retired service men and woman to get the medicine that is best for them.

If you are a Tricare beneficiary and have had your compounds denied please contact us at PublicAffairs@pccarx.com. We will help look into the reason why and help to get you taken care of.

CMS Coverage of Compounded Medications

The Medicare program provides health care coverage to nearly 50 million individuals, including seniors and individuals with disabilities with significant health care needs. As one of the largest health care providers in the country, Medicare often plays an integral role in setting the standard for care for other payers. However, when it comes to providing seniors with access to needed medications prescribed by their physician, Medicare is sorely lacking in providing access to compounded medications.

Medicare’s coverage of compounded prescriptions varies widely depending on the site of care. This not only makes it confusing and challenging for patients to get their needed medications, but it also inefficient and concerning for physicians trying to get their patients the proper treatment.

Ensuring seniors have access to the medications and treatment options they need must be a top priority for the Medicare program. PCCA is committed to working with Congress, the Centers for Medicare and Medicaid Services, physicians, and seniors to improve and rationalize Medicare coverage to ensure that the doctor-patient relationship remains strong and all available treatment options are covered.