Easier access to urgent care, higher pharmacy co-pays and a coordinated formulary between the Defense and Veterans Affairs departments are among the changes service members, families and retirees will see in health care as a result of the fiscal 2016 defense authorization bill.
If the legislation gets past a threatened veto from President Obama over unrelated issues, Tricare beneficiaries will see an uptick in co-payments for prescription medications at retail pharmacies and by mail once the bill, HR 1735, becomes law.
Under the bill, co-payments for a 30-day generic prescription filled at a Tricare network pharmacy would rise to $10, from the current $8, while prescriptions for brand-name drugs will rise to $24, up from $20.
Generics still would be available at no cost by mail, but a 90-day prescription for a brand-name medication by mail would rise to $20, up from $16, and medications not on Tricare's formulary would increase to $49, from $46.
Prescriptions would continue to be available at no cost to customers using military pharmacies.
The Defense Department had proposed, and the Senate had supported, even higher co-pays for most medications and a more aggressive schedule for increasing co-pays through 2025.
But under an agreement forged between the House and Senate, pharmacy co-pays will continue to rise at a slower rate, one that is relative to any cost-of-living adjustments.
If the COLA increases the amount of a co-pay by 50 cents or more, the co-pay would be rounded up to the nearest dollar. If the increase is less than 50 cents, co-pays would remain the same but the increase would carry over to the following year, which means that whenever the aggregate increase topped 50 cents, co-pays would rise to the next-highest dollar.
Lawmakers who negotiated the final bill said they "rejected more than 60 percent of the proposed increases to Tricare pharmacy co-payments requested by the DoD and approved by the Senate," preferring instead to include "modest adjustments ... at the minimum amount necessary" to help offset costs of a new military retirement overhaul that is also part of the defense bill.
The bill also requires DoD and VA to create a joint formulary that includes the same medications for conditions including pain, sleep disorders, psychiatric illnesses and any other diseases the departments want to include.
The joint formulary should be in place by June 1, under the bill.
A uniform drug formulary between the departments was among the health care recommendations made by the Military Compensation and Retirement Modernization Commission earlier this year. Lawmakers also had pressed for a joint formulary out of concern for veterans who were leaving active duty and having difficulties filling needed medications at VA pharmacies.
A Government Accountability Office investigation found that just 43 percent of medications in the DoD formulary also are offered through the VA system.
The defense policy bill contains a number of other provisions designed to improve care and services for Tricare beneficiaries, including one that could prevent overuse of emergency rooms. That provision calls for a three-year pilot program to allow Tricare beneficiaries to go to urgent care without pre-approval.
Under the pilot, the Tricare nurse advice line would advise beneficiaries on how to get care at the "most appropriate level," according to the bill, including assisting them in deciding whether to go to an ER, wait for regular doctor's hours or go to an urgent care facility.
Currently, Tricare Prime beneficiaries must obtain pre-approval for urgent care visits. Lawmakers said the pilot program has the "potential to lower health care costs for DoD" while providing beneficiaries easier access to care.
Patricia Kime is a senior writer covering military and veterans health care, medicine and personnel issues.
