Community Alert
Changes in Insurance Options for TRICARE Patients
Last fall, military families in the TRICARE network were notified by Express Scripts, Inc., the pharmacy benefit manager (PBM) for TRICARE, that they would need to choose from a small, select list of providers to serve their clotting factor needs in the future. Numerous hemophilia treatment centers (HTCs) and homecare providers, including Coram, have been cut from the Express Scripts network, while Express Scripts’ own specialty pharmacies remain in-network. Unfortunately, many TRICARE families who have been using Coram and other providers since their children were born were asked to choose from a narrowed list of specialty pharmacies. Unlike Coram, many of these do not meet standards of service established by the Medical and Scientific Advisory Council of the National Hemophilia Foundation.
Taking Action
Coram has worked cooperatively with Express Scripts to safely transition its customers to pharmacy providers within the narrowed TRICARE network. Moreover, we continue to work closely with TRICARE to ensure its members can once again access the high quality services that Coram provides.
If you would like to express your own concerns regarding these changes, including any service failures since the transition, please contact the TRICARE pharmacy operations center at 866.275.4732 (option 8), or via email at PECWEB@amedd.army.mil. In addition, please notify your members of Congress who oversee the TRICARE program. You can easily find your members of Congress by visiting www.house.gov and www.senate.gov and using the search functions at the top of the screens.
The Historic Perspective
In 2002, when factor products started to become more expensive as a result of medical advances, insurance companies who had clients with thousands of employees began hiring pharmacy benefit managers (PBMs). The job of the PBMs was to monitor costs for hemophilia products, examine employees’ claims, manage their prescriptions and find ways to lower premium costs for employers.
However, between 2002 and 2004, the PBMs began buying homecare companies in order to establish their own specialty pharmacies to sell factor. While some perceive this as a conflict of interest, the nation’s three largest PBMs, including Express Scripts, are now among the most dominant factor providers in the country.
Factor providers such as homecare companies and hemophilia treatment centers compete to become “in-network” with an insurance company. Usually the insurance company limits the number of in-network providers but also offers numerous choices for their clients within that list.
Express Scripts is the PBM hired by the Department of Defense to monitor military families covered by the TRICARE Pharmacy Services benefit. Therefore, Express Scripts’ recent notification that their “in-network” provider list would be sharply cut has forced many families to scramble for a new, unfamiliar provider.