Tricare drug co-pays would rise under Senate plan

By Patricia Kime, Staff writer

The co-pays that Tricare beneficiaries fork out for prescription drugs would nearly double over 10 years under legislation proposed by the Senate Armed Services Committee.

The panel’s draft 2016 defense authorization bill, released May 22, calls for increasing co-payments on all brand-name prescriptions starting in 2016, raising co-pays for generics beginning in 2019 and then continuing to incrementally boost all co-pays through 2025.

Medications would continue to be offered at no cost through military pharmacies, as well as to survivors of those who die or died on active duty, and medically retired personnel and their family members.

Legislators said they need to raise the fees to ensure that the Pentagon’s budget meets military readiness and national security needs in future years.

“In deliberations with the House last year, there was an agreement to reconsider any proposed co-pay changes if inadequate defense budget levels continue … in the committee’s view, the defense budget situation is no better this year,” committee members wrote in an explanatory report accompanying their bill.

Tricare beneficiaries saw pharmacy co-payments rise by $3 for most prescriptions just a few months ago, in February.

The new Senate plan, if approved as part of the final defense bill, would require the Pentagon to keep co-payments steady next year for generic prescriptions obtained through network pharmacies or by mail — $8 for a 30-day prescription at a retail store and $0 for a 90-day prescription by home delivery.

But prescriptions for brand names would increase, to $28 from $20 for a 30-day script at a retail store and to $28 from $16 for a 90-day prescription by mail.

Fees also would increase for drugs not listed in Tricare’s formulary, to $54 from $46 for a 90-day prescription.

By 2025, co-payments would be:

  • $14 for either a 30-day generic prescription at a network pharmacy or a 90-day generic prescription by mail.
  • $46 for a 30-day prescription of a brand-name drug at a retail pharmacy or a 90-day prescription.
  • $92 for a 90-day prescription of medication not listed in Tricare’s formulary.

The House version of the defense bill does not include a similar fee hike. Instead, it proposes that the Defense Department establish a pilot program of preferred retail pharmacy networks to see whether such a program, currently available in Medicare, would reduce government costs.

Other health-related items included in the Senate’s draft bill:

  • A stipulation that DoD publish the average wait times for patient appointments at military hospitals and clinics as well as public data on patient safety, quality of care and health outcomes at military hospitals and clinics.
  • A requirement that members of the Selected Reserve be allowed to enroll in Tricare for up to 18 months after discharge under other-than-adverse conditions.
  • A provision that DoD develop a system by which mental health specialists could apply for and be designated as able to understand and treat, behavioral health conditions related to military service and a requirement that the department maintain a list of these providers.
  • A provision that Tricare allow beneficiaries up to four urgent care visits a year without prior authorization.
  • A requirement that DoD ensure Tricare beneficiaries can transfer between regions without experiencing any delays in health care related to the moves.
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