Doris Spatz takes a once-a-day pill, Kisqali, to keep her metastatic breast cancer in check. As a patient in the Defense Department health system, she can fill routine prescriptions at a military pharmacy without a copay but also has the option of using a regular pharmacy through Tricare, the Defense Department\u2019s private health care program.<\/p>\n

Spatz found a local pharmacy in her Alexandria, Virginia, neighborhood and was getting the life-preserving medicine there.<\/p>\n

That is, until Oct. 24, when Express Scripts, the pharmacy benefit manager for Tricare, dropped nearly 15,000 pharmacies from its network. Many of them were small, independent pharmacies, like Neighborhood Pharmacy of Del Ray, where Spatz was a customer.<\/p>\n

That decision created problems, according to Doris\u2019 husband, Dr. Michael Spatz, because the breast cancer drug is not carried by every pharmacy. And some larger chains require patients to use a branch of their business known as a specialty pharmacy for pricey or scarce medications for complex diseases.<\/p>\n

\u201cExpress Scripts told us, \u2018You can just go to CVS,\u2019\u201d Michael Spatz said. \u201cBut that was kind of a mess because you can\u2019t just go into CVS and get a $1,500 medicine. You have to be in their special pharmacy system.\u201d<\/p>\n

About 27% of all pharmacies in the Tricare network are no longer covered, leaving more than 400,000 military beneficiaries affected. The move has upset customers and many independent pharmacies and has raised concerns among some service member advocates and lawmakers, especially those in rural states, who feel it disproportionally affects rural veterans.<\/p>\n

In a September letter<\/a> to the Defense Department, U.S. Sen. Jon Tester (D-Mont.), chair of the Senate Veterans\u2019 Affairs Committee, said: \u201cNo longer able to rely upon their local pharmacy to access needed medications and in-person pharmacist counseling, they would be forced to drive long distances to find corporate in-network pharmacies or be funneled into Express Scripts\u2019 mail delivery program. That is unacceptable.\u201d<\/p>\n

Many of the affected pharmacies knew they would be dropped from the network at the end of the year because they didn\u2019t accept Express Scripts\u2019 terms, which included reduced reimbursement rates. But they were surprised by the early ejection, said Ronna Hauser, senior vice president of policy and pharmacy affairs at the National Community Pharmacists Association. \u201cThis was a very botched rollout of this new network and unfortunate, ultimately, for the patients,\u201d she said.<\/p>\n

The Military Officers Association of America, an advocacy group for active-duty and retired personnel, said it was pressing for a reversal of the decision.<\/p>\n

While acknowledging that the Defense Department is under pressure to control health care costs, Karen Ruedisueli, the association\u2019s director of government relations for health affairs, called the change \u201cunprecedented and shortsighted.\u201d<\/p>\n

Peter Graves, a spokesperson for the Defense Health Agency, which oversees medical care and services for 9.6 million beneficiaries, including service members, military retirees, and their families, said the Pentagon does not participate in contract negotiations between its pharmacy benefit manager and retail pharmacies.<\/p>\n

But, he said in an emailed statement, the changes will not inconvenience many of the people in the program. Roughly 95% of beneficiaries will have access to at least two network pharmacies within a 15-minute drive, he said, and \u201c99.8%\u201d will have access within 30 minutes.<\/p>\n

\u201cThe Tricare retail network will continue to meet or exceed Tricare\u2019s standard for pharmacy access,\u201d Graves said. \u201cBeneficiaries will continue to have many convenient, local in-network options for filling their medications, including those beneficiaries in rural locations.\u201d<\/p>\n

In a separate email, Express Scripts spokesperson Justine Sessions said the decision to leave the network was \u201cup to the pharmacy and\/or the wholesalers that negotiate on their behalf.\u201d She added that roughly 80% of pharmacies being dropped from the network had fewer than 50 prescription claims in the past six months from Tricare and that 25% had none. Sessions said Express Scripts has a team dedicated to contacting the \u201csmall percentage of beneficiaries that may be impacted by these changes\u201d and helping them move their prescriptions.<\/p>\n

\u201cOur charge is to ensure Tricare beneficiaries can access their prescription medication safely, affordably, and conveniently, and at the best value for the Department of Defense and taxpayers,\u201d Sessions said.<\/p>\n

The transition is especially problematic for a small group of Tricare beneficiaries who are chronically ill, have a disability, and receive infusion medications in their homes, according to pharmacists.<\/p>\n

Logan Davis, vice president of trade at Vital Care Infusion Services, which serves customers in 30 states, said that the company\u2019s services are covered under Tricare\u2019s medical benefit but that the medications used for the infusions are often purchased from independent pharmacies.<\/p>\n

The move could delay care for patients with chronic conditions such as rheumatoid arthritis, myasthenia gravis, and Crohn\u2019s disease, Davis said. Swapping out intravenous prescriptions isn\u2019t simple, he said.<\/p>\n