Protect Access to Medication for Kids in Military Families:

1. Reverse Cuts to the TRICARE Retail Pharmacy Contract
2. Reject Dangerous Fail First Policies that Disrupt Care
3. Require Flexibility in Contracting and Utilization Necessary to Meet Children’s Unique Needs

SUMMARY

TRICARE, the health plan for uniformed service members' families and retirees, covering 2.4 million children of military connected families, has just made major cuts in its pharmacy network. After an immediate outcry from families and providers, the Department of Defense announced it will re-open the network briefly in December, but with no substantive or reimbursement changes, only minimal impact/improvement is expected.  Furthermore, through the retail pharmacy contract, TRICARE is implementing policies that require children with well controlled regimens to drop their current medications and try other options until they fail, instead of allowing continuity of care on the medication prescribed by the child’s provider. 

BACKGROUND

The recent retail pharmacy contract with Express Scripts Inc (ESI) incentivized major cuts to the independent and community based pharmacies.  TRICARE cut 15,000 pharmacies or about one/third of the options, as well as specialized pharmacies which are often needed to craft medication that will meet unique needs of children. The policies embedded in ESI authorization forms, and not subject to the protections of federal regulation notice, publication and comments before implementation include requiring children to “fail first” on “preferred” medication before they can obtain or even refill the medication prescribed by their provider. 

Children, especially those with chronic or complex medical conditions, often need customized medication for their size, weight, age and complexities, and customized pharmaceuticals are not generally available from commercial pharmacies. It has been estimated that in a children’s hospital as much as 70 percent of the medications dispensed require some type of pharmacy customization. For example, medications commercially manufactured for adults are often packaged in doses too large or too strong to be given to children and must be divided down into smaller doses or diluted, must typically be preservative-free, and often must be converted from solid to liquid for infants who cannot yet eat. 

Put yourself in the shoes of the parent who was given a bottle of large pills, something typical for an average size adult of 150 pounds, and told to “break it into 27 pieces” for an infant just released from the neonatal intensive care unit. Typical chain pharmacies usually do not provide the kind of explicitly detailed modifications unique to that child. Families generally rely on a hospital’s in-house pharmacy or an independent community based pharmacy to provide these exacting requirements. The very pharmacies that are being cut from Tricare’s network are the ones that provide this service.

Another medication reality that requires flexibility to meet children’s unique needs, is that children rely on “off-label” use of medications, i.e., drugs that have not been tested specifically for children. Although pediatric providers are adamant advocates for more pediatric specific research, and improvements have been made, most medications are not tested specifically on children, for many reasons, and children’s access to this off-label medication when needed must be protected with flexibility in coverage policies.

Pediatric-specific considerations are often not taken into account under a limited – or fail first- formulary structure, as very specific and sometimes off-label medications are frequently prescribed to children, particularly for unique child populations, such as children with chronic or rare diseases. Many new gene therapies must be administered when first symptoms are identified in order to be most effective. Any delay in providing these drugs due to the requirement to “fail first” or to seek an exception, could lead to worsening of the condition or result in higher costs. 

Similarly, children grow and develop quickly and cannot afford the disruption of care and harm that can occur while “failing first” on the “preferred” formulary medication, or EITHER being forced to use off-label medication or being refused off-label. This is particularly concerning for children being treated for epilepsy or a mental health condition. These child patients spend months working with their doctor searching for a drug that works with their body chemistry. Under a limited formulary structure the child’s current prescription may not be covered causing a potentially problematic interruption to the child’s care plan. 

THE PROBLEM

Tricare and ESI are engaging in an extremely dangerous practice given the current and acknowledged mental and behavioral health crisis among our nation’s youth. In the name of what? Saving a little bit of money on the children of our service members? Many of the side effects of behavioral health medications have extremely dangerous ramifications for youth, including suicidal thoughts. This is not the direction we should be sending the children and teens of our military families!

ACTION NEEDED 

Instead, Tricare should allow flexibility in contracting to include hospitals’ specialty pharmacies, community-based and independent pharmacies that are necessary to meet children’s unique needs and covering in a timely manner the drugs that are considered appropriate by the prescribing provider.

Families are reporting that they are resorting to filling necessary and successful medications on their own, out of their own pockets. This is not sustainable, and not a way to sustain the Force of the Future. Military families deserve better, and it is sure to be reflected in recruitment and retention trends if access to care continues to be impeded.  

We the undersigned, respectfully request that the Department of Defense and the Defense Health Agency to REVERSE the Tricare cuts to critical pharmacy providers and REJECT dangerous fail-first policies that will harm our most vulnerable children of military and veteran retiree families covered by Tricare.

Join us:

1. Sign our Petition, to be shared with the Defense Health Agency
2. Share the impact to your family in the comments (please no personal identifying information in the public comments) to help us fight back against these changes!