The Department of Defense (DOD) and Express Scripts Inc. (ESI), the company selected to manage the TRICARE Retail Pharmacy program (TRRx), are working together to promote a high quality, cost-effective pharmacy benefit. A key factor in making this benefit a success is the mandatory generic drug program, which has been in place for more than 10 years. This program requires that prescriptions be filled with the generic product, if one is available.
When the TRICARE Retail Pharmacy program contract was implemented on June 1, 2004, through ESI, the generic policy was enforced consistently, resulting in denials of prescriptions for brand-name drugs for many beneficiaries accustomed to receiving brand-name products even when generic equivalents were available. In order to allow DOD an opportunity to develop a more permanent solution for these beneficiaries, a 120-day grace period was granted and subsequently extended another 60 days while TRICARE Management Activity finalized options. This waiver was scheduled to expire on Dec. 13, 2004; however, there has been a slight delay due to patient notifications.
DOD as contracted with ESI to mail a letter to all patients who were receiving a brand-name drug on June 1, 2004, for which there was a generic equivalent available, stating that the beneficiaries' current prescription for the brand-name medication will be honored until they have obtained all the refills remaining on their current prescription.
Additionally, the letter will state that when a new prescription is presented at their retail pharmacy for the brand name medication, once the brand refills have expired, the generic equivalent will be dispensed and the brand-name medication will not be covered unless medical necessity for the brand name medication has been established. In order for medical necessity to be established, one or more of the following must occur:
- Patient must experience, or would be likely to experience, significant adverse effects from the generic medicine;
- The generic medicine has resulted in, or is likely to result in, therapeutic
- Patient has previously responded to the brand-name medication, and changing to the generic medication would incur an unacceptable clinical risk.
The letter continues with a description of generic drugs and an explanation of their safety, therapeutic effectiveness and cost effectiveness. The patient is informed that they may switch to the generic by asking their physician to write a prescription for a generic drug or by asking their pharmacist to refill the medications with a generic equivalent when permissible by state pharmacy regulations.
The letter discussed above has been written and DOD is currently compiling the list of addresses for beneficiaries affected by the existing policy. Once all addresses have been compiled, the affected beneficiaries will receive their letter and will be given 30 days before any action is taken with regard to this policy.
We understand that patient treatment decisions are between the patient and the doctor. If the physician feels that it is medically necessary for the patient to continue to receive the brand-name version of the medication instead of the generic, then the physician should be directed to call the TRICARE Retail Pharmacy program Prior Authorization Line at 1-866-684-4488 prior to the patient obtaining the next prescription at the retail pharmacy in order to first obtain the letter of medical necessity. Unless the patient has an approved letter of medical necessity before they fill the new prescription, they will have to pay the full cost of the medication in addition to the cost share.
For additional questions regarding the prescription drug benefit, please contact Express Scripts at 1-866-DoD-TRRx (1-866-363-8779) to speak with a patient care advocate.