Tricare to No Longer Cover Some Prescription Pain Killers

Tricare officials are rolling out a new prescription drug clearance system that will block from coverage some ingredients used in compounded medications like pain killers, officials announced March 13.

The changes, which will go into effect May 1, are designed to cut the health insurer's pharmacy costs by no longer paying for compounds they considers unsafe or ineffective, Tricare officials said. They will most heavily impact prescription pain killers, which make up the majority of compounded medication filled by Tricare, they said.

A compounded medication is a drug mixed with one or more non-FDA approved ingredients designed to alter the drug to fit the need of the person taking it. For example, children often take compounded medications to alter the drug's dosage to their weight, remove dyes to which they are allergic or turn a pill medication into a liquid.

For pain management, compounds are often used to turn pain medications into creams or sprays to target specific areas. Specialized compounding can also adjust the dosage to the size or pain tolerance of the patient.

But a top Tricare official said in a Military.com interview that the effectiveness of those specialized pain medications are not always "supported by evidence." At least one Military Treatment Facility (MTF) has complained recently about a marketing agent for a pain medication compounding pharmacy soliciting potential customers in the MTF's pharmacy waiting room, he said.

"We've seen several examples where compounding pharmacies are trying to go out and do direct marketing to patients," Dr. George Jones, Tricare's pharmacy chief said. "Unfortunately there are some bad actors out there that have tried to exploit this opportunity of interest in pain management with claims that may not quite by supported with the evidence."

Compounding agents cost Tricare more than $514 million in 2014 and are on track to exceed $2 billion for 2015, officials said. Yet those agents make up only 0.5 percent of the total number of prescriptions provided by Tricare. Tricare currently fills compounded medication for about 40,000 users a month, Jones said.

The vast majority of compounded medications will continue to be covered, Jones said. Although he declined to give an example of pain medication compounds that will no longer be included, he said popular compounding agents such as gabapentin and ketamine will still be covered. He was also not able to provide a percentage the compounding agents that will still be covered.

Right now, Tricare chooses which compounded medications to cover based on the screening of a single ingredient submitted by a pharmacy. But the new system operated by Tricare's pharmacy subcontractor, Express Scripts, will allow officials to screen every ingredient included in any given compound medication. If all ingredients do not match the accept list, coverage will be denied, they said.

Tricare officials decided which compounding ingredients will be on the list based on FDA standards for compounding agents released in July 2014, Jones said.

Ingredient screening will be instantaneous though the online Express Scripts system. When an ingredient is denied, the pharmacist will be notified about which one and given the option to call Express Scripts to explore alternatives.

Tricare users who wish to can file a "prior authorization" form and appeal to Express Scripts after a denial. The appeal will be processed in no more than five days, Jones said.

To avoid a disruption in service while Tricare processes drug appeals, officials will pay for some no longer covered compounds on a case-by-case basis, Jones said.

Tricare users who have a have had a compounded medication filled in the last 30 days will soon receive a letter by mail notifying them of the change.

-- Amy Bushatz can be reached at amy.bushatz@military.com