Express Scripts’ Contract With Department of Defense May Limit Access to Lifesaving Medication for Tricare Patients

Advocates from the AIDS Healthcare Foundation (AHF) protested outside Cigna’s Bloomfield, Connecticut, corporate headquarters on Tuesday, October 18, 2022, following a decision made by Cigna’s pharmacy benefits manager (PBM) Express Scripts to add arbitrary penalties and fees to independent and specialty pharmacies that are out-of-network.

The Express Scripts decision removes the option for Tricare beneficiaries to get prescriptions at the pharmacies of their choice. The National Community Pharmacists Association (NCPA) CEO B. Douglas Hoey, PharmD, MBA, warns that “access to needed medications for Tricare beneficiaries is in peril.”

This decision is estimated to impact hundreds of thousands of beneficiaries relying on certain pharmacies (or locations) to get prescriptions—those who cannot get their prescription at the pharmacy of their choice may fall out of care.

Consequently, patients may lose access to the potentially lifesaving treatments that specialty and independent pharmacies can provide, especially for patients with critical illnesses such as HIV, among other illnesses.

“Our David and Goliath battle between independent and smaller pharmacies and PBMs continues with this Cigna protest in Bloomfield [on] Tuesday,” Tracy Jones, national director for Grassroots Mobilization Initiatives for AIDS Healthcare Foundation, said in a press release.

In a recent analysis, experts suggested that the contract, made with the US Department of Defense (DOD), could shrink the retail pharmaceutical network by 15,000 pharmacies.

And who is expected to be impacted? NCPA explained in the press release that the answer is mainly independent and community pharmacies.

While large chains, such as Kroger and Walmart, are on the chopping block, thousands of independent pharmacies are also out of network. This could have incredible consequences on beneficiaries in urban and rural areas, who are mostly served by independent pharmacies.

“The situation has gotten so out of hand that we must continue to speak out against PBM abuses and health care consolidation to help protect struggling smaller mom and pop and independent pharmacies nationwide,” Jones said in the press release.

The changes enacted by Express Scripts to the DOD contract are expected to be effective on October 24, 2022. The start date has taken many by surprise, as the assumption has been that these changes would not be implemented until the beginning of 2023.

PBMs are (theoretically) designed to facilitate easier access to drugs. However, 3 PBMS (CVS Caremark, Express Scripts (Cigna), and OptumRX) currently control over 75% of the US market.

Express Scripts alone controls 24% of the PBM market in the US, according to Becker’s Hospital Review. Now, as the number 2 largest US-based PBM, Express Scripts enacting this change to the DOD contract will be felt across the landscape of the multibillion-dollar industry market, forcing many pharmacy owners and managers to make some tough, and quick, financial decisions.

NCPA has discussed the issue with legislators, some of whom consider the contract “unacceptable”—other legislators, including representatives from Arkansas and Louisiana, have written letters citing concerns and questions about the decision.

“Tricare patients earned their benefits, and it is imperative that they retain convenient access to their health care providers,” Hoey said.

References

Cigna. AHF to Protest CIGNA for Shortchanging Pharmacies: ‘Cigna Doesn’t Care!’. Businesswire. October 18, 2022. Accessed on October 19, 2022. https://www.businesswire.com/news/home/20221017006022/en

National Community Pharmacist’s Association. NCPA to DOD: Express Scripts Jeopardizing Tricare Patients’ Pharmacy Access. October 19, 2022. Accessed October 19, 2022.