The TRICARE benefit should protect military families with comprehensive health care coverage. That is why MOAA continues efforts to improve how TRICARE deals with Tier 4/non-covered drugs.
Recently, MOAA has urged the Defense Health Agency (DHA) to re-evaluate Dexilant as a Tier 4 drug and has asked Congress to require an appeals process for drugs excluded from TRICARE coverage.
TRICARE used to cover all Food and Drug Administration-approved medications, placing them in one of three tiers – Generic, Brand Name and Non-Formulary – with varying copays for beneficiaries. Now, drugs the DHA categorizes as “Tier 4/non-covered” are excluded from coverage under TRICARE – they aren’t covered at retail pharmacies or through the TRICARE Pharmacy Home Delivery program, and they cannot be obtained at military treatment facility (MTF) pharmacies.
[MORE ABOUT TRICARE: MOAA’s 2020-21 TRICARE Guide]
What is the origin of this TRICARE pharmacy program change? Congress included a provision in the FY 2018 National Defense Authorization Act allowing the DoD Pharmacy and Therapeutics (P&T) Committee, which resides in the DHA, to identify drugs to be excluded from TRICARE coverage. The P&T Committee may recommend, and the DHA director may approve, exclusion of a drug determined to provide very little or no clinical effectiveness.
While DHA has categorized relatively few drugs as Tier 4, MOAA believes there is already one drug – Dexilant – that has been moved to Tier 4 in a way that does not align with congressional intent to limit Tier 4 drugs to those with little to no clinical effectiveness.
Dexilant is a proton pump inhibitor indicated for the treatment of gastroesophageal reflux disease (GERD) and the maintenance of healed erosive esophagitis. Approximately 19,000 TRICARE beneficiaries were taking Dexilant when it was moved to non-covered status.
[IS YOUR PRESCRIPTION COVERED? Check TRICARE’s Formulary]
Since Dexilant was moved to Tier 4, we have heard from numerous MOAA members and other TRICARE beneficiaries about how this decision has negatively impacted them. Most tried other prescription and non-prescription alternatives that have not worked as well as Dexilant or have left symptoms unchecked.
MOAA research suggests TRICARE’s non-coverage of Dexilant is out of step with commercial plans and other government payers. According to Dexilant’s manufacturer, Takeda Pharmaceuticals, Dexilant is covered by approximately 80% of commercial plans, 70% of Medicare Part D plans, 70% of fee-for-service Medicaid and 45% of managed Medicaid plans.
We have provided beneficiary feedback and coverage comparisons to DHA and urged officials to restore Dexilant to the TRICARE formulary. The P&T Committee included a reassessment of Dexilant coverage on its February 2021 agenda; we are waiting to learn the results of that meeting.
Coverage Appeals
Charges for Tier 4/non-covered drugs do not count against the catastrophic cap, exposing TRICARE beneficiaries to unlimited financial risk from non-covered prescription drugs. In addition to pushing for Dexilant to be reinstated to the TRICARE formulary, we have urged Congress to require an appeals process that would allow TRICARE beneficiaries to make the case for coverage of Tier 4 drugs because of medical necessity.
We believe DHA has the authority to implement an appeals process, so legislation may not be necessary. We continue to advance this issue with DHA and the Armed Services Committee staff in both chambers to achieve an appeals process for Tier 4 drugs.
At a minimum, TRICARE coverage should align with that of high-quality commercial plans. The extraordinary challenges and sacrifices associated with military service should earn a comprehensive health care benefit. We will continue our efforts to ensure TRICARE beneficiaries are protected from unexpected coverage gaps.
MOAA is tracking member communications on Tier 4 and using them to drive advocacy efforts. Are you taking a drug that has been moved to Tier 4/non-covered status? Please share your experience at legis@moaa.org.
