NCPA CEO: Express Scripts Is Limiting, Restricting Veterans’ Access to Health Care

This Veteran’s Day, NCPA CEO B. Douglas Hoey, PharmD, MBA, discusses the implications of Express Scripts’ elimination of the pharmacy of choice option for TRICARE beneficiaries in their contract with the Department of Defense.

This Veteran’s Day, Pharmacy Times® interviewed B. Douglas Hoey, PharmD, MBA, CEO of National Community Pharmacists Association (NCPA), on Express Scripts’ decisions to eliminate the option for TRICARE beneficiaries to obtain their prescriptions at their pharmacy of choice.

Pharmacy Times®: When did the decision by Express Scripts to eliminate the option for TRICARE beneficiaries to obtain their prescriptions at their pharmacy of choice occur, and when will it be enacted?

B. Douglas Hoey: Well, the bid for the contract was actually accepted last year, and it was supposed to go into effect on January 1 of 2023. However, Express Scripts has decided to accelerate the impact, and so it went into effect October 24, 2022. So it went into effect over 2 months earlier than it needed to.

Pharmacy Times®: What has been the Department of Defense’s (DOD’s) reaction to this decision, and does the DOD have the ability to address this contract issue internally, or in other words—was the approval of this contract change an oversight or something else?

B. Douglas Hoey: Disappointing and yes, so far the reaction has been underwhelming, and I'm not a veteran, but I certainly respect the work of our military and our veterans, and it's been very underwhelming as far as the response from DOD that 15,000 pharmacies have been cut out of the network. So the access to pharmacies and the care that pharmacies provide has been dramatically restricted.

And yes, DOD does have the authority to make changes. Now they do have some budget constraints they have to live up to so that can limit some of their options. But they are the ones with the authority to make the changes. But it's been disappointing to get the reaction to the cutbacks and care that, unfortunately, our members of the military are having to absorb.

Pharmacy Times®: What is the argument Express Scripts is making regarding why this change is beneficial/necessary?

B. Douglas Hoey: So we really haven't heard from Express Scripts on this. Our questions have really been to the customer, which is the Department of Defense, not to the contractor, which in this case, is Express Scripts. I would anticipate though their answer would be that it would be a cost cutting move that by eliminating pharmacies that there are some cost savings for DOD—I'm sure that would be their pitch.

We've asked the question, what's in it for Express Scripts—because we know that there are incentives to drive veterans and members of the military into Express Scripts’ mail order service, and so we believe that's really Express Scripts’ incentive is to drive more business into their mail order pharmacy. But I think the answer they would give and probably the pitch they sold to DOD was that somehow this was going to cut costs.

Pharmacy Times®: What are some real-world consequences of this decision by Express Scripts for patients?

B. Douglas Hoey: Some of the consequences for members of the military and veterans is that they can't go to the pharmacy of their choice. So they may have to drive a farther distance. Express Scripts have told DOD that the of the beneficiaries must have a pharmacy within 15—either 15 minutes or 15 miles of their pharmacy. But how that's measured is up for debate.

We've asked for the study that shows that this network complies with that geo access standard and have not been given access to the research that was used to say that this the network that Express Scripts is using actually complies with that. So access to pharmacies, access to patient care is one big consequence.

Another is lack of access to the services, especially, of course, those independent pharmacies provide, such as unit dose packaging. So if a patient is in a veteran member militaries and long-term care facility, system living facility, and they're using an independent because independent unit dose bubble packs, medication, they're probably not going to get that at some big box chain that is in the network.

And it does seem like most of the big box chains, with the exception of Walmart, appear to be in the network. So, it's really a big box network network.

Pharmacy Times®: What is the process for updating this contract—does this need to be addressed by Congress or the courts?

B. Douglas Hoey: It really needs to be addressed by DOD. We have reached out to Congress, asking them to inquire within DOD because DOD certainly doesn't have to answer to a pharmacy association or to a pharmacy. But they should have to answer to Congress as their funding source and their sources of oversight.

So far over 150 members of Congress have responded to our request for inquiring with DOD of what's going on, and how do these changes impact members of the military and veterans. To the best of our knowledge, those inquiries have not been responded to. Congress is awaiting responses to those, but so far, again, to the best of our knowledge, there's been no reply from the Department of Defense to over a third of Congress asking what's going on—which I find pretty shocking, by the way that, again, to our knowledge, that there's been no reply.

Pharmacy Times®: How does this issue underscore a broader problem regarding pharmacy benefit managers’ impact on the ability of health care professionals to effectively treat patients?

B. Douglas Hoey: Yeah, it's underscores that PBMs are getting into the practice of medicine and practice of pharmacy either by eliminating providers, or using some of the quote unquote cost saving tools that PBM is like to talk about, like PAs, which is really a license to practice medicine is a PA where PBM decides what deserves a PA and what doesn't. So it underscores that PBMs are filling the seat of the provider and dictating to the provider how they will practice in some areas.

It also underscores that the freedom for patients to be able to choose their provider is being restricted by PBMs. And I would say, I believe this is the third long term contract in a row that DOD has given to Express Scripts for this contract, it may be longer than that—it’s a multibillion-dollar contract. So, there's taxpayer money involved, there's access involved, there’s veterans and their care that's involved, and I think there's a lot of questions that DOD should be asking their contractor. And as taxpayers and as health care providers, we should be demanding through our elected representatives answers to those questions, because it's our taxpayer money and it's our members of military and our veterans who fight for our freedom that are being impacted.

Editor's Note (updated on November 15, 2022 at 14:00 ET): Cigna has announced that independent pharmacies will be given another chance in early December to consider the opportunity to participate in the TRICARE network. Additionally, Cigna noted that the December contract solicitation will be sent directly to pharmacies who either declined the recent contracting opportunity directly or who are affiliated with a pharmacy services administrative organization that declined the contracting opportunity on their behalf.