Impact of a uniform formulary on military health system prescribers: baseline survey results

E. Comments from Survey Respondents
In this appendix, we provide selected comments that we received from surveyrespondents. The comments have been organized according to the topicsdiscussed in Chapter 5 and are divided into three sections—general commentsfrom direct-care system prescribers; comments from direct-care prescribersspecifically in response to a question on changes they would make to the content,policies, and/or procedures of their MTF’s formulary; and general commentsfrom purchased-care system prescribers.
NOTE: Some of the comments listed in this appendix apply to more than one
topic category, and therefore they appear more than once.
General Comments from Direct-Care System Prescribers
Pharmacy Staff
[My MTF’s] pharmacy is exemplary. They are attentive to the patient’s time,restrictions, and physician prescribing habits, and go the extra mile toprovide comprehensive reviews of efficacy and cost analysis prior toaddition or deletion of any pharmacy item. Working with the constraints offunding and ability to provide, they graciously exhaust all their manpower.
And may I say, they do it so gracefully. Never a complaint. Never a quiver.
Our pharmacy staff is very approachable, friendly, and responds to allrequests. We have our own pediatric pharmacy for non-controlledsubstances 8 to 4 Monday through Friday. The CHCS ORE system iswonderful. There is little or no difficulty in dealing with our pharmacystaff—they are very helpful. The only problem yet to be solved is the VERYlong wait to have a prescription filled (up to three hours) at the mainpharmacy. Automation improved this to 30 minutes, then it relapsed rightback to horrible. We lose patients because of this and [because of limited]parking.
I think our P&T committee does an excellent job with cost control but needsto communicate better with physicians so they are more a part of the processand not made to feel like their hands are being tied.
The pharmacy is one of the best departments at my MTF.
The formulary is NOT a problem. What is a problem is the chronic under-manning of our pharmacies. Those who are in our pharmacies are oftenpoorly trained. If you want to do something useful for us providers, look atthe manning of our pharmacies. I think you’d be shocked at the dangerousundermanning, which results in poor patient and provider satisfaction,increased errors, and patient harm.
The main difficulty I have is in communications with the pharmacy—gettingin touch with someone in the know about the formulary. Militarypharmacists are quite busy, I know, but generally I can call a civilianpharmacy and, within a reasonable period of time, talk with the pharmacistfor advice, availability of medication, etc. It is not so with the militarypharmacies.
As a provider and a customer/user of the system, I think it is much betterthan the outside civilian pharmacies.
In general, I have been pleased with military pharmacy services.
Formulary Content
The pharmacy is so slow to put LAWH on the formulary or drugs likeGlitazone.
Our pharmacy has been very receptive to the needs of the HIV-positivepatients in keeping the latest antiretrovirals in stock.
Make cold packs available to active duty [personnel] and dependents.
I work at two area MTFs, geographically separated by approximately 30miles. The formularies differ dramatically, and the rules regulatingNMOP/local civilian pharmacy use and amounts of “chronic use” medicinesgiven vary so dramatically that both doctors and patients find it confusing.
Local P&T committees differ, and personal experience will often influencecommittee decisions. I feel policies and formularies should be standardizedto the maximum extent, and the NMOP should provide variability andflexibility.
On several occasions, medicines that are on our MTF formulary are notactually in the hospital. One of these medications was needed on an urgentbasis. I have had to refer [patients] to a pharmacy outside the MTF becausethe medications were not available for over two weeks.
Some formulary decisions are mandated by changes in the Triserviceformulary. This can lead to changes that affect thousands, such as at ourMTF.
Suggest eliminating all OTCs [over-the counter medications] to decreaseoverall workload for providers and pharmacy.
(1) One of the greatest problems is the frequent formulary changes. In mysix-year cycle here, I have experienced [many] changes: These changes do notoccur at the same time and require patient contact [simply] to changemedications. Also, I get very offended as a board-certified internist when Iam restricted from prescribing medications outside of my subspecialty. (2)Stop switching formulary drugs so often. (3) Don’t switch brand names onpatients’ prescriptions (i.e., substituting one brand name or generic drugwith another one when patients refill prescriptions).
Cost
Reasonable cost containment has been abandoned at the provider level.
Rather than a proper history and physical exam, unnecessary expensivetesting is performed and unnecessary expensive drugs are prescribed (e.g.,the emergency room will prescribe Ofloxacin at $0.97 per tab when Septra at$0.12 per tab will suffice. I find this offensive and the result of physicianlaziness.
I have heard that the pharmacy budget drains our resources in the MTF dueto the large number of prescriptions [that are] filled. Perhaps charging a co-pay on some or all medications would ease the financial burden. The co-paycould be minimal, e.g., $1.00.
I attended P&T committee meetings when I first arrived here and becamecompletely frustrated by the process, the lack of insight, the lack ofwillingness to listen to reason, the attitude that the job of the P&T committeeand the formulary was to save the hospital’s budget and discourage outsideproviders [from] writing the medications they desired for their patients. Ihave had my prescriptions changed by the pharmacy without my beinginformed—at the expense of the patient’s health (this is practicing medicinewithout a license, as far as I’m concerned). Waiting time at any MTF foroutpatient prescriptions, especially because of restrictions on the duration ofprescriptions [is long], even for [medications for] chronic conditions thatneed to be refilled monthly; will not be dispensed [if the patient] shows up[two or three days early]—must be after 30 days.
Quality of Life
Bigger hindrance is promotion. I will get out as soon as my 20 years are in.
No problems in my files, just haven’t done CGSC, which didn’t use to be arequirement. Changing the rules in midstream is inappropriate. More andmore administrative [hurdles].
I am currently risking burnout with increased administrative demand andthe increased number of patients I see. I am not sure how long this increasedoperational tempo can continue.
We are doing more traveling to see patients at local clinics. Each local MTFformulary is different. We need to have a Triservice formulary that is thesame for all local MTFs. MEDCEN formularies are more comprehensive andshould also be equal at [all MTFs]. Many times, the electronic screens are notcurrent. A drug will be listed as non-formulary, but when I call thepharmacy, the drug is on the shelf. Pharmacy courier services are providedfrom [my MTF] to [most MTFs in this area but not all]. This is inconvenientto patients [in those MTFs] who have to drive to [my MTF] to pick up a drug[their MTF] does not carry. Short of a special drug request, this decreasesavailable manpower time due to patient travel time to pick up medications.
Also, the local MTF pharmacies often cannot make an automatic refillnumber the default for certain drugs without going through [my MTF]; thisis inconvenient. We waste time doing it manually each time we prescribe—carpal tunnel syndrome occurs!! Thanks for doing this. Hope this is helpful.
Outside Prescription/Pharmacy
[My MTF] has done a very good job of balancing the many competing factorsof funds, accessibility, and formulary. However, the outside prescriptions area tremendous drain on dollars and create a vast drain on personnel resourcesand on parking within the facility. Again, outside prescriptions should go tooutside-TRICARE no-co-payment pharmacies for TRICARE Prime patientsand to co-pay [pharmacies] for non-Prime [patients].
The MTF providers often have our prescriptions scrutinized more closely to[generate] cost savings to compensate for off-base Rxs that are costinappropriate.
Outside prescribers should have the same restrictions as military providers.
Civilian providers seeing MTF beneficiaries outside the MTF tend toprescribe more expensive agents as first line [medications].
Quality of Care
Overall, I think our pharmacy does an incredibly good job in meeting themedication needs of the patients. I think that patient satisfaction, and morethan just monies, should impact the formulary. Also, patient compliancewith daily medication is more apt to occur than with a cheaper QID [fourtimes a day] medication, for example. Also, community standards need to beaddressed, especially in oncology. If we can’t prescribe Rituxan, even thoughit is FDA approved, we need to be able to refer patients to places where theycan get life-saving treatments.
Some formulary decisions are mandated by changes in the Triserviceformulary. This can lead to changes that affect thousands, such as at ourMTF.
I attended P&T committee meetings when I first arrived here and becamecompletely frustrated by the process, the lack of insight, the lack ofwillingness to listen to reason, the attitude that the job of the P&T committeeand the formulary was to save the hospital’s budget and discourage outsideproviders [from] writing the medications they desired for their patients. Ihave had my prescriptions changed by the pharmacy without my beinginformed—at the expense of the patient’s health (this is practicing medicinewithout a license, as far as I’m concerned). Waiting time at any MTF foroutpatient prescriptions, especially because of restrictions on the duration ofprescriptions [is long], even for [medications for] chronic conditions thatneed to be refilled monthly; will not be dispensed [if the patient] shows up[two or three days early]—must be after 30 days.
I think my patients have excellent pharmacy benefits, even though they maynot appreciate it.
Half of my time is spent with a fleet (ships assigned active duty). Thispopulation often has difficulty (still) obtaining their medications for six-month deployments—especially expensive prescriptions (regardless if it is aformulary or basic core formulary drug). This is an obstacle to care that mustbe eliminated. Our active duty fleet patients are why we exist. I have foundthat this large MTF is much more difficult to prescribe from than themedium-size MTF and branch medical clinic MTF that I have been assignedto, which I find interesting since they [the latter two] have more pharmacybudgetary constraints. I do not prescribe an outside provider’s Rx and willnot do so if I am not following the patient [over the course of] this diagnosis.
I feel it is bad medical/prescriptive practice.
The formulary is NOT a problem. What is a problem is the chronic under-manning of our pharmacies. Those who are in our pharmacies are often poorly trained. If you want to do something useful for us providers, look atthe manning of our pharmacies. I think you’d be shocked at the dangerousundermanning, which results in poor patient and provider satisfaction,increased errors, and patient harm.
We are doing more traveling to see patients at local clinics. Each local MTFformulary is different. We need to have a Triservice formulary that is thesame for all local MTFs. MEDCEN formularies are more comprehensive andshould also be equal at [all MTFs]. Many times, the electronic screens are notcurrent. A drug will be listed as non-formulary, but when I call thepharmacy, the drug is on the shelf. Pharmacy courier services are providedfrom [my MTF] to [most MTFs in this area but not all]. This is inconvenientto patients [in those MTFs] who have to drive to [my MTF] to pick up a drug[their MTF] does not carry. Short of a special drug request, this decreasesavailable manpower time due to patient travel time to pick up medications.
Also, the local MTF pharmacies often cannot make an automatic refillnumber the default for certain drugs without going through [my MTF]; thisis inconvenient. We waste time doing it manually each time we prescribe—carpal tunnel syndrome occurs!! Thanks for doing this. Hope this is helpful.
Part of my time is spent with a small population of chronically ill pediatricyoung adult adolescent patients who are much healthier with the newmedications that are available. These medications are very expensive butmarkedly improve quality and quantity of life. Our MTF has supported ouravailability of these medications after appropriate provision of theinformation on research showing the effectiveness [of these medications].
I am grateful on behalf of these patients.
Non-Formulary Approval Process
There needs to be an expedited approval for “minor meds” that cost less than$20 to $30 per average prescription. This would allow more flexibility inadding/changing medications with little impact on overall cost.
CHCS is an incredible help in prescribing for my patients. Overall, I am verypleased with the formulary and process to get non-formulary meds.
The MTF pharmacy is generally accessible and willing to prescribeappropriate non-formulary medications.
In my specialty practice, I am never denied medications that I havedetermined are most appropriate for my patients.
I [utilize] mail order when drugs are expensive or not carried on ourformulary.
Other/Miscellaneous
[Respondent named two health plans] are the worst TRICARE contractors interms of pharmacy benefits that I’ve experienced. Their first and only priorityis to pinch the patients access to top-quality pharmaceuticals and frustrateproviders trying to help the patient.
I would love to have the PDR [Physician’s Desk Reference] incorporated intoCHCS so that it could be easily accessed without going out of the program.
(1) The electronic prescribing on CHCS can be very helpful, especially inregard to allergies and interactions. This is a good feature. (2) Time is a bigproblem—15-minute appointments for geriatric patients on multiplemedications means squeezed assessment time for medication review. (3)Formulary is a good idea and contains cost, but not enough physicians areconsulted [on it].
I think our pharmacy/formulary is a very reasonable one, and non-formulary requests, when reasonable, are handled positively andexpeditiously. The single most frustrating aspect of my work is spendingtime on tasks which could/should be done by others—such as faxing,photocopying, and helping people get appointments—because the “system”is obstructive.
While CHCS has been helpful, it has never been easy to determine which[drug] choices in a particular class were available.
CHCS is getting more burdensome. More and more typing and sitting at thecomputer by physicians hurts patient care.
As a specialist, I prescribe only the drugs that are my specialty and refer allother issues back to the primary care manager—hence, my knowledge of the“formulary” is really limited to the drugs I use for my scope of practice.
Likewise, I request that those drugs that I feel necessary for my practice beadded to the formulary. Therefore, all the questions you ask regarding mysatisfaction or familiarity really reflect my or my colleague’s endeavors toplace whatever we need on the formulary.
Comments from Direct-Care System Prescribers in
Response to Question on Recommended Changes to
MTF Formulary
Question 18. If you had the opportunity, what changes would you make to the
content, policies, and/or procedures of your MTF’s formulary?
No Problems
None. I think our system works quite well.
Formulary is reasonable for my needs.
None at this time. We have a pretty good system at present.
I am basically satisfied with the contents of our formulary.
No significant changes [to recommend].
Our prescribing is all computer-based. All medications are labeled asformulary or non-formulary. Special drug requests are honored withreasonable speed and accuracy. The occasional glitch is [usually somethinglike] a misplaced piece of paper when special requests are submitted.
I have not encountered any roadblocks to prescribing medications at [myMTF]; however, my subspecialty has a narrow range of medications [thatare] used.
None. They have been very responsive.
I have found that I can get almost any non-formulary drug my patients needby submitting a request and justifying the need of the medication.
[My MTF] pharmacy is doing a good job of supplying medications requested.
Non-stocked items are available to the patient in 24 to 48 hours. For the typesof medications that I prescribe that are non-formulary, this has not createdany detriment to the patients’ health. A system is in place to automaticallyevaluate the addition of frequently requested non-formulary items todetermine the advisability of adding them to the formulary. A non-formularyprescription requires a handwritten prescription that is signed by staff(trainees cannot sign). [Supervisory body] evaluates and educates providerson appropriate drug usage. This is the best system for meeting the needs ofthe patient and the provider that I have seen in 16 years of active duty.
Have more personnel to run the pharmacy as they are overworked. Yet,
despite all this, they’ve done an outstanding job!! It will also help the facility
have a person working in the after-hours clinic.
MTF is doing a fine job. When medical necessity dictates them, drugs havebeen obtained.
I feel that our pharmacist and P&T committee do an excellent job ofsupporting provider ordering. Have no complaints with present system.
No change. Pharmacy is doing an excellent job.
None—works well as is with minimal problems.
Cost
Drop expensive drugs that have no therapeutic advantage, e.g. (1) Ortho 777is more than $15 per pack versus Trileven at $1.25 per pack; (2) Preman is$0.22 per tab versus Estrace at $0.02 per tab. Stop pharmacy rep visits tophysicians.
For higher-priced medications, I have a comment about possible cheaperalternatives. [Respondent listed several alternative medications in the write-in section of the survey.] Have an automatic annual review by pharmacy and medical department ofmedications for addition or deletion from the pharmacy. Currently, it occursevery few years. To protect the MTF budget and expand the formulary, Iwould like to see all outside prescriptions filled by TRICARE (private)pharmacies or by the mail order national pharmacy—with no co-pay forTRICARE prime but co-pay for non-prime.
Have retail cost of drug printed out at the time the medication is dispensed.
This may educate patients about actual costs, may cut down on waste, andmay inspire patients to appreciate their pharmacy benefits.
Requests for non-formulary items are taking up to a month at present to beprocessed! This is a change from the previous four to five days. This isburdensome for the patient and doctor. This process needs to be facilitated!Increase education on pharmaceutical costs and pricing.
Prefer that when formulary changes are made, everyone is not forced to use anew drug if the old drug is working. It seems penny wise and pound foolishto subject thousands of patients to a different drug if their previousprescription worked well. It generates a lot of visits, phone calls, andconfusion. [It also generates] repeated lab tests and [there could be] additional side effects (i.e., with Lipitor versus Baycol; Prevacid versusProtonix).
Non-TRICARE beneficiaries pharmacy budget should not come out of MTFmoney. This places a burden on the MTF to not add new drugs to theformulary due to concerns of misuse by civilian providers locally. In the end,TRICARE Prime beneficiaries suffer due to restrictive formulary policies thatcannot control civilian prescribing patterns! Develop a policy by which a patient pays the difference in the cost of a drugif a formulary alternative exists but the patient demands [the drug] anyway.
Increase the pharmacy budget to allow physicians to prescribe more current,proven, state-of-the-art medications.
Encourage drug companies to offer better discounts on drugs.
I would be interested in knowing how much money is spent on OTCmedications prescribed.
If the DoD mandates that the MTF must fill all prescriptions presented byoutside providers, then the DoD should fund the MTF to cover the expense.
Capitated costs to my MTF severely hamper my ability to practice medicineas compared with a large tertiary center.
Cost is not the bottom line at all times.
Pharmacists’ role is only to give pharmacologic and cost information, notguidelines on use.
Pharmacy funding DoD-wide needs to be worked out so that [the MTFs] arenot always “going under” at the end of the fiscal year.
Filling outside scripts has made the MTF formulary more “restrictive”—expensive drugs such as Cox 2’s are “available” only through NDRs (newdrug requests). To place [such a drug] “in formulary” opens it to all, and theoutside providers may not be following our guidelines. Our MTF has at least“streamlined” the process and has made it relatively easy to submit NDRs.
Patients in our system do not have any incentive to help contain cost—theproviders are sandwiched in between the patients demanding the “newdrug” and the pharmacy demanding cost be contained; a co-pay systemwould help this.
No closed categories; better funding.
Cost comparison analysis across a class of drugs such as AEM (includingmedication costs and lab tests needed, as well as [costs arising from]complications), as well as efficacy comparison [are recommended].
Non-Formulary Issues
The oversight for special purchase/non-formulary items is too strict. Otherthan that, I think we have an outstanding formulary and pharmacy staff.
A DoD formulary is a good goal, but the newer drugs should be obtained bythe requesting provider until the type of drugs in a class has a track record.
I usually don’t get notified if a non-formulary drug is denied until the angrypatient calls. Need more feedback from pharmacy.
I understand the need for cost containment but feel that if there is a medicinethat better suits a patient, it should be easily accessible. While the process hasbeen improved, I feel it still has too much red tape binding the providers’hands.
Less administrative [procedures] to get non-formulary drugs.
Requests for non-formulary items are taking up to a month at present to beprocessed! This is a change from the previous four to five days. This isburdensome for the patient and doctor. This process needs to be facilitated!Increase education on pharmaceutical costs and pricing.
A formulary in hard copy. Update to new medications on the market. Lesshard copy paperwork for non-formulary drug.
Simply, if a drug is truly required clinically and is not formulary, theapproval process should be simpler and more streamlined.
Publish an updated formulary on the Web every month that is easy to lookup, especially by drug classes and therapeutic categories. Allow “key access”to “restrictive drugs” universally to the most senior staff.
I would distribute the minutes of meetings to providers along with regularlyscheduled updates of formulary change. Would review policies regardingthe process for requests from specialty clinics for non-formulary prescribing.
At our facility, the number of subspecialty clinics with the ability to prescribeVioxx is so large that they can’t fit the list [of subspecialty clinics] on a singleline. Patients are inappropriately placed on [Vioxx] and then expect us tocontinue prescribing it.
[The pharmacy should] have cardiac medications that are supported byevidence-based medical efficiencies, regardless of cost.
Make changes to non-formulary MTF drugs available electronically, as longas they are electronically signed by a staff physician (notresident/intern/trainee). Why? Because most non-formulary drug requestsare not denied, you might as well do them electronically and allow anydenials to occur electronically to provide feedback to the provider.
Some drugs are placed on special order status only to restrict their use, eventhough the P&T committee knows their use is justified in some cases. Doinga special drug request for these [special orders] is annoying.
Decrease the amount of time taken to process a new drug request. Somemedications I requested be added to formulary, which I routinely use (e.g.,DDAVP nasal spray/tablets for bed-wetting), were denied for cost issues oralternative forms (e.g., Claritin tablets were denied even though we haveClaritin liquid on formulary), so I have to write civilian prescriptions for[Claratin tablets], which I assume cost more. But overall I am a member ofour P&T committee and very pleased with the overall responsiveness tocover newer, more-effective medications even though it may be more costly.
The problem is NOT the formulary. We have a retrospective review processfor non-formulary requests. Thus, the patient is never kept waiting whileapproval is obtained. The prescribing physician is the approval authority.
The P&T committee reviews non-formulary requests after the fact to identify[questionable] provider patterns. This process has not been abused by ourproviders. Also, if a non-formulary drug is being ordered by multipleproviders on a routine basis, this medication is automatically discussed atP&T [committee meetings] for possible addition to the formulary.
Prospective review of non-formulary requests is irritating to providers andhas the potential to harm patients. It should be eliminated throughout theNavy.
The ordering of non-formulary items at [my MTF] is very easy, but there isstill a three- to five-day delay in starting [these prescriptions]. So, I just send[the orders] downtown. I wish we could shorten the time to med to one day.
Not having to resubmit special requests for “off-formulary” drugs that arerefills.
Most frustrating are the irrational restrictions on my prescribing practice.
Fully certified M.D.’s should not be held to same restrictions as physician’sassistant’s, nurse practitioners, and other non-M.D. providers!! I am a board-certified pediatrician and am fully trained to prescribe medications for reflux,asthma, allergies, antibiotics, etc. At [my MTF], I am unable to prescribemany of these drugs without specialty approval. Also, Zyrtec standarddosing is one-half tab per day, which is ineffective for many and not what isrecommended by the manufacturer. The acne medications and eczematopicals that are available are inadequate at best, and many of the usefulproducts that I use in my private practice I have to refer my military patientsto dermatology or allergy [specialists] or send [them] to an outsidepharmacy.
I am a primary care provider. I am restricted from prescribing medicationsfor common medical problems because they can only be prescribed byspecialists (e.g., Vioxx, risedronate, Celexa, Lamictal). Therefore, in order torefill or prescribe these medications, I am forced to send [patients]to aspecialist or write a non-formulary drug request. This is frustrating to mebecause my prescribing patterns are actually more cost conscious than thoseof most specialists and [this process] requires more visits and more timespent per patient.
I believe physicians should be able to prescribe what they deem best suitstheir patients. I try to use cheaper agents first, but I should be given morefreedom to switch [based] on my clinical judgment.
Decrease the time and paperwork associated with prescribing non-formularydrugs.
Formulary Content
Maybe consider adding some pediatric preparations.
Add Lipitor. Certainly a pharmacy committee that does not havephysician/nurse practitioner representation for an MTF should not beallowed to make changes to the formulary. And at least, any proposedchanges should be distributed to ALL providers in that MTF PRIOR to thechanges being made.
Add glucosmine and chondroifin sulfate.
We need to re-examine the choice of antibiotics we are carrying; update themwith much better pediatric choices. Need to be able to make changes in amore time-efficient manner.
My biggest complaint is how difficult it is to add or change a formulary item.
It takes several hours of my time to write up/type the request (I have nosecretary who can do it). I have to cancel clinic time to attend the P&Tcommittee meeting. Most times, the request is denied the first time around. Ihave to get more supporting data and return to the P&T committee. This is atime-consuming process that takes a concerted effort over several months toadd or change one medication. Often that [process] provides only a “trialperiod,” and I have to return with more data to justify final approval. This istrue for all medications—there is no easy way for me to get experience with anew therapy. NDRs require me to fill out the form, submit it, wait to hear if itis approved, and wait to get a message that the medication is available, andthen I have to enter the prescription and personally call the patients so theycan pick up the Rx. This process is so burdensome that I almost never try new acne creams or other advances, and as a result my patients “get by” witholder therapies. No doubt the hospital saves money by keeping the systemburdensome for the providers. I wish I could give out samples, like all otherdermatologists.
Stop the frequent changes to formulary. I often have to change a patient’s Rxabout once a year to adjust for formulary shifts and not for medical reasons.
Add Lipitor back to the formulary; the automatic switch caused loss ofcontrol of lipids (in previously controlled population), more monitoringcosts, and a lot more provider time to check LTTs and monitor previouslystable lipids. (Baycol is not as effective.) More choices for hormone replacement therapy.
Don’t know. I am satisfied with what we have, although the formulary couldbe more complete and current.
As a dermatologist: (1) I would add Differin Gel (Adapolene); (2) I wouldadd a quality sun block to use in high risk patients; (3)I would add Valtrex totreatment for Herpes Zoster and herpes simplex virus [HSV].
I would distribute the minutes of meetings to providers along with regularlyscheduled updates of formulary change. Would review policies regardingthe process for requests from specialty clinics for non-formulary prescribing.
At our facility, the number of subspecialty clinics with the ability to prescribeVioxx is so large that they can’t fit the list [of subspecialty clinics] on a singleline. Patients are inappropriately placed on [Vioxx] and then expect us tocontinue prescribing it.
Easier availability of Viagra, when clinically indicated.
I have not encountered any roadblocks to prescribing medications at [myMTF]; however, my subspecialty has a narrow range of medications [thatare] used.
I think our system works well and is responsive to the requests of physiciansand the needs of patients. In a perfect world, there would be no budgetinglimitations, and I could prescribe any brand of medication I wanted (anytype of growth hormone, for instance). Also, it would be nice to hand outsome OTC items (e.g., alcohol swabs, etc.). What is challenging here is thatthere are four to six different facilities on the same computer system, buttheir formulary contents are all different! [The pharmacy should] have cardiac medications that are supported byevidence-based medical efficiencies, regardless of cost.
Quicker addition to the formulary of medication on the market that civilianproviders use to practice [their] standard of care.
I would revamp the entire formulary to begin with, acquiring a list fromproviders of the medications they WANT to prescribe, with justifications.
Emphasize the cost-savings to the U.S. Army that would be realized bypurchasing and prescribing through the MTF, rather than through NMOP oroutside pharmacies. Make those cost savings available as increasedpharmacy budget monies to the MTFs.
Take ALL over-the-counter medications off the formulary! Placing orders forthese is a big waste of provider time! Discontinue all OTC products and unproven remedies.
Addition of a Cox-2 Inhibitor and Viagra.
If you can justify stocking the pill form, it seems a bit schizophrenic not tostock the liquid form for patients (i.e., children) who can’t swallow pills (forexample, biasin).
Larger selection of clinically effective meds with different dosing options,such as once a day instead of four times a day, rather than basing selectionsof drugs solely on costs.
Increase variety and patient options.
No closed categories; better funding.
None. Possibly quit supplying OTC meds to save money.
Make formularies within different military MTFs consistent. [My MTF]pharmacy carries different ACE [angiotensin converting enzyme] than [otherMTFs within the same system]. This makes it difficult to prescribemedications for patients to pick up at other sites.
Patient Issues
Make prescribing policies clear to patients.
While avoiding “fads,” it is important to update available treatments forchronic illness (i.e., diabetes or HIV).
Once a patient is on a certain medication and it’s working, and both thepatient and physician are satisfied, then the patient’s medication should notbe changed to another drug in the formulary, even if the new drug is equallyeffective.
Process
I usually don’t get notified if a non-formulary drug is denied until the angrypatient calls. Need more feedback from pharmacy.
Currently, we use electronic prescribing via CHCS. This works adequatelyand is fairly easy for me to tell what is on formulary and what isn’t whileprescribing. The one thing that could improve it would be a more friendlyuser interface! (This is a CHCS-wide problem, not one limited to formularyor prescribing concerns, however.) Not having to deal with DoD mail-order system—took two hours for them tofax me forms!! Allow optimization of CHCS so that I may be allowed to order a prescriptionfor a beneficiary from another MTF within our region, allowing me to choosethe MTF easily within CHCS. The pharmacies within our region and DoDhave suboptimal reimbursement practices.
Choose a single mechanism for prescribing all non-formulary drugs. [Now,the] procedures for approval change based upon which drug is involved.
Procedures seem to vary even with the same drug from week to week. I endup completing all possible procedures/forms to ensure medication isapproved. I am also provided with little feedback to know if medication isapproved or not. I assume no news is good news!! Prefer that when formulary changes are made, everyone is not forced to use anew drug if the old drug is working. It seems penny wise and pound foolishto subject thousands of patients to a different drug if their previousprescription worked well. It generates a lot of visits, phone calls, andconfusion. [It also generates] repeated lab tests and [there could be]additional side affects (i.e., with Lipitor versus Baycol; Prevacid versusProtonix).
Renewal of current prescriptions works well. I wish renewal of expired ordiscontinued prescriptions could be retrieved and renewed as easily ratherthan having to generate a new Rx in CHCS.
Not certain why the day’s supply and quantity are not linked in an Rx. Manyinpatients receive Rx on discharge with two-weeks’ supply with refills, butare unable to get the refills because the phone-in refill [service person] thinksit’s a 30-day supply and [the refills] are denied. This generates a lot of extrawork and/or the patients stop using the medication because they had troublerefilling it.
Our formulary should be listed by drug category with the preferred (low-cost) drug listed first over less-preferred (high-cost) drug. For example, Icould type in “anti-depressant” and gets lists of SSRIs [selective serotoninreuptake inhibitors], tricyclics, MAO [inhibitors], and then click on SSRI andsee a list with Paxil, Prozac, and Zoloft with their relative costs. It is difficultto find what drugs are on a formulary by classes. There are times whenpatients have requested medications, and I have had them filled outside theMTF even though they have recently been added on our formulary [becausethey were added] without my knowledge.
When new drugs are established as the drug of choice for certain classes,policies for automatic substitution should be instituted for appropriatepatient education. This responsibility should fall to the MTF and not theindividual provider.
The electronic (CHCS) formulary is not user friendly. We should be able totype a category and get options. If a drug is not on the formulary, we shouldbe told the alternatives.
Quicker addition to the formulary of medication on the market that civilianproviders use to practice [their] standard of care.
The only difficulty is when a given drug in a particular class is the“preferred” drug for a while (like Zyctec), only to be replaced by somethingelse (like Allegra) as the preferred drug. I am not going to change all themedications for patients who are doing well on the original.
Evaluate the necessity of having new medications [that are] more efficacious,on the formulary, especially if the patient has tried other medications and[they are] not helping.
Pharmacy and Therapeutics [committee] should get input from the specialistfor adding or deleting medicines.
Eliminate unnecessary drugs (now being done here) and unavailable drugs.
Easier access to new drugs and have them added to the formulary morequickly.
Have more physician involvement in order to integrate clinical and patientcare concerns. I find it offensive that pharmacists are controlling myprescribing activities and limiting my practice of medicine by institutingnarrow-minded and dogmatic pharmacy protocols. “Value” in yourquestionnaire is assumed to denote dollars. There is more to medicine thanmoney. I am able to stay within the confines of our formulary most of thetime, but my choice to prescribe outside that formulary should not be bureaucratically challenged, especially by pharmacists and non-clinicalpersonnel.
Combine the formularies in the National Capitol Area. Patients should beable to visit the closest MTF and get refills or new prescriptions.
Cut back on non-Prime prescriptions from non-MTF (civilian) providers.
Electronic requests for non-formulary drugs.
Removal of OTCs or OTCs available to patients without a prescription.
Allow SPP medication requests to be filled at satellite clinics for the patient’sconvenience.
DoD should have one formulary—most conversions are started due to[transfers] from one MTF to another.
Make it easier to add medication to the formulary.
(1) Standardize the process. (2) Different medications [should not] requiredifferent forms. (3) Pharmacy never gives the patient the form, so I have totry to find one. Clinic does not always have one. (4) Sometimes I’m not surewhat form is needed.
Need more coordination of formularies in the National Capitol Area(Washington, D.C.) between the Air Force, Army, and Navy. Particularly forconsultants, it can be difficult to care for people if they can’t get a drugrefilled at their local MTF and have to get it at consultant’s MTF only or[through a] civilian source.
(1) Get rid of OTCs—patients waste valuable appointment slots for “refills”of OTCs. (2) DoD should allow for samples—it’s the only way we can gainexperience with new drugs.
[There should be] electronic processing of “special drug requests.” Theserequests [now] require the physician to hand-carry the form through theapproval process or [else] it gets left on someone’s desk indefinitely.
Better, searchable drug database with classes of drugs and costs available [inthe database]. Needs to be quick and easy to use.
(1) Updated formulary. (2) Updated computer program for prescribing.
Computerized formulary with drug class groups.
Rules/Restrictions
Remove specialty restrictions for some drugs and place such drugs underrequest for approval by specialist.
Disallow Rx by civilian providers of patients who are not TRICARE Prime.
Non-TRICARE beneficiaries’ pharmacy budget should not come out of MTFmoney. This places a burden on the MTF to not add new drugs to theformulary due to concerns of misuse by civilian providers locally. In the end,TRICARE Prime beneficiaries suffer due to restrictive formulary policies thatcannot control civilian prescribing patterns! Restrict less medications to specific services. Rather, educate providers inregard to cost, side effects, and appropriate use. Give feedback as needed toproviders in regard to their use of expensive/third-line medications.
Don’t block any Rx from specialists, only family doctors.
I would allow certain medications to be restricted by specialty. This wouldprevent overutilization of some expensive medications by providers whomight not have the training to appropriately prescribe certain medications.
[But it would still] allow the specialist the ease of routine prescriptionwriting rather than going through the non-formulary approval process.
Certain drugs are controlled by the pharmacy by permitting only certainsubspecialists to use them. Examples include sumatriptan, mirtazapine, andcelecoxib. I find this more exasperating than obtaining a new drug orderrequest to circumvent restrictions on non-formulary drugs. If these drugs areto be tried on a trial basis, a consult [to a specialist] has to be generated.
Less restriction of prescribing (i.e., specialists only prescribing for Vioxx orMetrogel is ridiculous).
Restrict beneficiaries with non-MTF prescriptions from using MTFpharmacy. Require that they use the non-MTF options that are now widelyavailable. That would allow the MTF formulary to expand without theconcern that the budget would go out of control because of prescriptions bynon-MTF providers.
Do not restrict drugs to specific specialties.
Restricting drugs to subspecialists results in consults to them that may beunnecessary (for asthma and allergy medications in particular).
The formulary in “theory” is fine. A problem occurs if you need to stepoutside the formulary. Many times I have experienced the attitude frompharmacy staff and commanders that [they think] I don’t know what I’m doing. As a result, many requests get denied. The main concern seems to bemoney, and only “lip service” is given to quality/standard of care. Pharmacypolicies are only one of the many reasons I am leaving the DoD.
Most frustrating are the irrational restrictions on my prescribing practice.
Fully certified M.D.’s should not be held to same restrictions as physician’sassistant’s, nurse practitioners and other non-M.D. providers!! I am a board-certified pediatrician and am fully trained to prescribe meds for reflux,asthma, allergies, antibiotics, etc. At [my MTF], I am unable to prescribemany of these drugs without specialty approval. Also, Zyrtec standarddosing is one-half tab per day, which is ineffective for many and not what isrecommended by the manufacturer. The acne medications and eczematopicals that are available are inadequate at best, and many of the usefulproducts that I use in my private practice I have to refer my military patientsto dermatology or allergy [specialists] or send [them] to an outsidepharmacy.
I am a primary care provider. I am restricted from prescribing medicationsfor common medical problems because they can only be prescribed byspecialists (e.g., Vioxx, risedronate, Celexa, Lamictal). Therefore, in order torefill or prescribe these medications, I am forced to send [patients]to aspecialist or write a non-formulary drug request. This is frustrating to mebecause my prescribing patterns are actually more cost conscious than thoseof most specialists and [this process] requires more visits and more timespent per patient.
Avoid prescriber limitations for refills—some drugs are limited-prescriptionmedications, limited to specific subspecialists. When I try to help a patientwith a refill, I am blocked [from doing so], and the patient must contact thesub-specialist.
Communication
Make prescribing policies clear to patients.
I usually don’t get notified if a non-formulary drug is denied until the angrypatient calls. Need more feedback from pharmacy.
After each P&T committee meeting, e-mail to ORE a list reporting thesummary actions taken/considered. Actually, it would be good for allcommittees to have a brief summary reported to the affected communityafter each meeting. Communication always enhances function.
A formulary in hard copy. Update to new medications on the market. Lesshard copy paperwork for non-formulary drugs.
Our formulary should be listed by drug category with the preferred (low-cost) drug listed first over less-preferred (high-cost) drugs. For example, Icould type in “anti-depressant” and gets lists of SSRIs [selective serotoninreuptake inhibitors], tricyclics, MAO [inhibitors], and then click on SSRI andsee a list with Paxil, Prozac, and Zoloft with their relative costs. It is difficultto find what drugs are on a formulary by classes. There are times whenpatients have requested medications, and I have had them filled outside theMTF even though they have recently been added on our formulary [becausethey were added] without my knowledge.
Publish an updated formulary on the Web every month that is easy to lookup, especially by drug classes and therapeutic categories. Allow “key access”to “restrictive drugs” universally to the most senior staff.
I would distribute the minutes of meetings to providers along with regularlyscheduled updates of formulary change. Would review policies regardingthe process for requests from specialty clinics for non-formulary prescribing.
At our facility, the number of subspecialty clinics with the ability to prescribeVioxx is so large that they can’t fit the list [of subspecialty clinics] on a singleline. Patients are inappropriately placed on [Vioxx] and then expect us tocontinue prescribing it.
The electronic (CHCS) formulary is not user friendly. We should be able totype a category and get options. If a drug is not on the formulary, we shouldbe told the alternatives.
Currently at my facility, there is no list. The only way to see if a drug is onformulary is to try to order it and see if it is there. An actual listing would behelpful.
Make changes to non-formulary MTF drugs available electronically, as longas they are electronically signed by a staff physician (notresident/intern/trainee). Why? Because most non-formulary drug requestsare not denied, you might as well do them electronically and allow anydenials to occur electronically to provide feedback to the provider.
More information on the cost of drugs versus alternative drugs within thesame class.
Updating printed formulary would be helpful—can better see the big picture.
Online CHCS drug data are fine. Sometimes I’m unaware of treatmentoptions and relative costs within a drug category. This needs to be in printform.
It would be beneficial to have a hard copy of the most current formulary andkey policies for prescribing medications at the MTF. These vary from place to place, and now in large MTFs many things are left to the provider to figureout as they go along. Not everyone in the facility has easy access to thepharmacy Web page. In addition, things out of stock or changes are not sentto the provider via CHCS e-mail. Again, one finds out through departmentmeetings or [when] trying to order things.
Make the formulary readily available, either printed or electronic, withupdates of drug preparations and dosage strengths available.
Notification of medical house staff prior to removal of drugs from theformulary to generate feedback and practical discussion of implications andalternative agents (with the overall goal of maintaining optimal patient care).
(1) Publish regularly in electronic/Web and printed formats. (2) Allowvisualization of all drugs in one class in CHCS. (3) Notification to physicianthat special medication is not only approved (we receive this [in a timelyfashion now] through CHCS SPP requests), but that the medication has beenobtained and “delivered” to patient.
(1) Open format for all physicians to have input (not just the director). (2)Regular meetings with pharmacist. (3) Dissemination of information topatients on why certain drugs are included or excluded. (4) Better feedbackwhen requesting non-formulary drugs. (5) Provide prescribing patternsthrough quarterly reports.
Give feedback on commonly prescribed non-formulary medicines. Trendsmay indicate a need to amend the formulary.
Better, searchable drug database with classes of drugs and costs available [inthe database]. Needs to be quick and easy to use.
Just send out updated formulary drug lists. Also, directions on the correctprocedure to acquire non-formulary medications if needed.
Please provide current hard copy formulary book on all drugs in ourformulary plus a field-specific one as well. Local MTFs in our area all havedifferent formularies, making it hard [for doctors] to know what’s availablewhen they travel to local MTFs or staff clinics. We need to be on the sameformulary. Too much time is wasted in seeing what is available at a givenMTF.
Remind providers about the non-formulary process; update [thephysician/prescriber] on additions via CHCS.
Miscellaneous
Better responsiveness and pro-activeness regarding the Advance PracticeNurse’s formulary.
Hiring more pharmacy personnel to cover the after-hours clinic will help theproviders to better concentrate on the patient care instead of dispensingactual (limited) medications, thereby reducing errors, which are increasingbecause of the pressure!! I do not agree with the policies on the HMG-CoA reductace inhibitors statins.
General Comments from Purchased-Care System
Prescribers
Pharmacy Issues
It would be nice for the patients if I could call or fax in prescriptions. Thelocal MTFs accept only written prescriptions. I don’t think it could be toohard to change this policy, and it would make it more convenient for thepatient.
I am very unhappy with the fact that the military base does not provide acopy of a formulary. I cannot prescribe medications on the formulary if I donot have knowledge of what is on the formulary! Furthermore, it is almostimpossible to get any help by phoning them. They will not allow refills byphone or fax like real pharmacies. My patients are very upset when theydrive 30-plus miles to the base to fill a prescription and are told that theprescription is not on their formulary. In my opinion, it is a poor excuse for apharmacy, but I guess that the price is right! Frustration is sometimes expressed [by patients] that [their] prescriptionscannot be filled 100 percent on base.
Having an in-house pharmacy that accepts TRICARE is very helpful. Theformulary from the local MTF is readily available and helps with prescribing.
Insurance Burden (Formulary Burden)
We participate in 30 different insurance plans. It is impossible or at least veryimpractical to keep track of the insurance plans’ formularies because of theextra time involved. We already spend as much time with insurancepaperwork as we do providing medical care and would actively resist anyadditional regulatory burden.
I find it impossible to keep up with formularies, as we see patients from somany plans and have little time to track down formularies, look up drugs,and such. I write prescriptions with no regard to what may or may not be ona formulary, and let the pharmacist call me if there is a problem.
Medicine, in general, is becoming less and less attractive due to insuranceand medication dictates, hassles, and constraints. I think many physicianswould retire ASAP if they had the means. I still enjoy my work, but probablyless so than five years ago. I was planning on working into my 70s, but I amnow reconsidering. I feel our medical system is really broken, and the[broken] pieces multiply each year.
Formularies are basically a good idea; however, with the large number ofinsurers each having a formulary, to look up the prescriptions on everypatient is time consuming and therefore not done. Additionally, whenconsidering medications on formularies, frequently medications available forone-to-two times a day dosing are left off in favor of four-times-a-daycheaper medications. Few people take [medications] four times a day,[which] minimizes the therapeutic effect. Dosing frequency or ease ofadministration must be considered an important factor when generatingformularies.
It is difficult to keep up with all the insurance companies’ formularies. Ialways ask my patients if they know if a certain medication is available at[the MTF]. I do sign all of my prescriptions on the “product selectionpermitted” side [of the prescription form]; however, this seems unacceptableat the [MTF]. By signing this, it should allow the pharmacist to make thesubstitution. I don’t have this problem with commercial pharmacies.
Patients are on health insurance plans that keep changing periodically, andformulary lists also keep changing very frequently. Given the immensenumber of plans that our staff has to deal with, it is very difficult to check onformulary plans every time one writes a prescription. Besides, patients whohave used a certain medication for many months (in some cases for years)should not be changing their medications.
I suppose formularies are a necessary evil to contain costs. I find them,however, to be extremely burdensome. Most of my TRICARE patients havethe mindset, “If I can’t get it for free (or very cheap), I don’t want it.” I try toprescribe the best and safest medicine, which at times means it is moreexpensive. I would like to see doing away with blanket rejections andonerous obstacles. Instead, [I would like to see] a tiered system where thepatients can still get what is best and safest for them just by paying a bithigher co-pay. Then, I would have to do fewer unnecessary lab tests andadditional office visits, [and I would have] fewer hoops to jump through.
Bureaucrats don’t know why a certain medication is best for a certain patient.
They don’t know the long history of what has been tried and failed orassociated with side effects already. I do.
I usually don’t have time to consider a patient’s insurance during ourencounters. I will often ask the drug reps if their products are on all theformularies or not. If one formulary doesn’t cover [a drug], I tend not to useit because I can’t keep track of all the different lists. Also, because I practicein a group, I may not be the one who has to change a medication because itisn’t on the formulary. The pharmacist may speak to a nurse who “runs itby” another doctor. Even if a drug is the most cost effective in its class, it may not work well for an individual. There needs to be more leeway [in what wecan prescribe].
Formulary/preferred drug programs are a pain!! Busy practices withcontracts with multiple insurance programs/health care systems areoverwhelmed with drug formulary/preferred lists (our practice [has] over 30[contracts]); it is impossible to keep up. Additionally, most [plans] routinelydeny appropriate drug coverage.
Formularies and tiered systems are very cumbersome for the practitioner. Wesee many insurance company patients and many formularies, which seem tochange all the time.
A burden is placed on physicians by faxed letters of rejection to switchbrands of medication to “formulary”[medications]. However, a better idea isto have patients know about alternative brands and let them decide on tryinga new agent (often when the incentive is the money that could be saved).
Being a middle person between insurance [companies] and patients isdifficult. If the insurance plan wants to save money with the patient’s OK,then approval by the physician would be appropriate and time saving.
Generally, I feel that formularies are useful for insurance companies.
However, in a busy practice, it is very time consuming to check formulariesfor each prescription. We care for patients [covered by] most insurancecompanies. Plus, every patient has his or her own preferences, effectivenessprofiles, etc.
Quality of Life
Medicine, in general, is becoming less and less attractive due to insuranceand medication dictates, hassles, and constraints. I think many physicianswould retire ASAP if they had the means. I still enjoy my work, but probablyless so than five years ago. I was planning on working into my 70s, but I amnow reconsidering. I feel our medical system is really broken, and the[broken] pieces multiply each year.
I am made bitter by the over-regulation; it is an abuse of our profession!When I go through a medical process, I want my decision to be respected asit is! Since EMTALA [Emergency Medical Treatment and Active Labor Act] hasmade emergency physicians the only legally mandated slave labor in theUnited States, there are far too many rules, regulations, formularies, andcontracts we are supposed to be familiar with, and not enough hours in theday.
Cost
We are frustrated by TRICARE’s abysmal reimbursement. Most doctors inthis geographic area are not [TRICARE] providers because of this. We foughtwith TRICARE over depoprovera coverage. I have to buy 96 units of depo toget the lowest price of $41.20 each. TRICARE pays $45 plus $12 copay. Whatbusiness can survive with such a narrow profit margin? TRICARE is theworst payer for depoprovera. [TRICARE] used to pay $31 [each], and Ialmost dropped my provider status over this. I feel military personnel shouldget the drugs prescribed at no cost to them. When I was in active duty, Iserved in the P&T committee and we were responsive to patient needs andcosts; it worked well. But managed care P&T committees are dishonest, and Icannot deal with the myriad formularies shoved my way. I have never seen aTRICARE formulary.
Drug costs are very, very important and need to be contained because theyare driving the increasing cost of medical care. On the other hand, drugcompanies would not increasingly be coming out with truly miraculous,new, and safer medications if they didn’t think they could make large profits[after] the tremendous costs of R&D and going through the FDA approvalprocess. I don’t know the correct balance of these two important aspects ofthe problem.
To get quality physicians to this area, where the population is significantlymilitary related, the emphasis has to shift from discounted fee for service toquality physicians (specialty based, board certified). With the emphasis ondiscounted fee for service, it is difficult to recruit quality physicians. This is adisservice to not only the CHAMPUS beneficiaries but also the community atlarge. Quality physicians cost less [in the long run] by providing better care.
Especially now that TRICARE payments [are more] in line with Medicarerates, the system should move away from who-gives-more-of-a-discount towho-are-the-better-physicians.
TRICARE patients are a welcome addition to our practice! Due toexceptionally low reimbursements in the other plans, we can only acceptTRICARE Standard. To expand patients’ opportunity for quality care and resources, [TRICARE should] consider raising reimbursements in acompetitive marketplace.
I don’t have a problem with a tiered co-pay for medications, but I have a realproblem with a formulary that won’t pay any of the cost of a medicationwhen other less-expensive medications have been tried and failed. The mainexamples are Concerta or Metadate, Adderall, Diflucan, Xapenex, andPulmicort (not just with TRICARE, but in general), and some formularieswon’t pay for any antidepressants that I prescribe for my adolescent patients;[then] the patient has to see a psychiatrist.
Patients need to be educated as to (a) why they have a formulary and (b) whatthe cost of their medications is. They are currently too removed from the truecost of their health care, including drug costs.
Most patients confuse price (cost) with value. Formulary Content
We are frustrated by TRICARE’s abysmal reimbursement. Most doctors inthis geographic area are not [TRICARE] providers because of this. We foughtwith TRICARE over depoprovera coverage. I have to buy 96 units of depo toget the lowest price of $41.20 each. TRICARE pays $45 plus $12 copay. Whatbusiness can survive with such a narrow profit margin? TRICARE is theworst payer for depoprovera. [TRICARE] used to pay $31 [each], and Ialmost dropped my provider status over this. I feel military personnel shouldget the drugs prescribed at no cost to them. When I was in active duty, Iserved in the P&T committee and we were responsive to patient needs andcosts; it worked well. But managed care P&T committees are dishonest, and Icannot deal with the myriad formularies shoved my way. I have never seen aTRICARE formulary.
As a fertility specialist, it does not make sense to me that TRICARE patientscan have certain fertility drugs or treatment only if they are seen at a basefacility. The drugs should be covered wherever the patient is seen if theyneed it.
I don’t have a problem with a tiered co-pay for medications, but I have a realproblem with a formulary that won’t pay any of the cost of a medicationwhen other less-expensive medications have been tried and failed. The mainexamples are Concerta or Metadate, Adderall, Diflucan, Xapenex, andPulmicort (not just with TRICARE, but in general), and some formularieswon’t pay for any antidepressants that I prescribe for my adolescent patients;[then] the patient has to see a psychiatrist.
I usually don’t have time to consider a patient’s insurance during ourencounters. I will often ask the drug reps if their products are on all theformularies or not. If one formulary doesn’t cover [a drug], I tend not to useit because I can’t keep track of all the different lists. Also, because I practicein a group, I may not be the one who has to change a medication because itisn’t on the formulary. The pharmacist may speak to a nurse who “runs itby” another doctor. Even if a drug is the most cost effective in its class, it maynot work well for an individual. There needs to be more leeway [in what wecan prescribe].
Quality of Care
To get quality physicians to this area, where the population is significantlymilitary related, the emphasis has to shift from discounted fee for service toquality physicians (specialty based, board certified). With the emphasis ondiscounted fee for service, it is difficult to recruit quality physicians. This is adisservice to not only the CHAMPUS beneficiaries but also the community atlarge. Quality physicians cost less [in the long run] by providing better care.
Especially now that TRICARE payments [are more] in line with Medicarerates, the system should move away from who-gives-more-of-a-discount towho-are-the-better-physicians.
Patients are on health insurance plans that keep changing periodically, andformulary lists also keep changing very frequently. Given the immensenumber of plans that our staff has to deal with, it is very difficult to check onformulary plans every time one writes a prescription. Besides, patients whohave used a certain medication for many months (in some cases for years)should not be changing their medications.
The big complaint by patients in the Denver area is that the closest MTFs thatprovide drugs are the Air Force Academy and Ft. Carson; both are inColorado Springs. Buckley AF base has an MTF (albeit small), but it does notprovide pharmacy coverage to the numerous dependents and retirees in theDenver area.
It is not reasonable to refill prescriptions by mail/fax. When this is done,patients frequently do not return for office appointments and checkups ontheir blood pressure, glucose, etc.
I suppose formularies are a necessary evil to contain costs. I find them,however, to be extremely burdensome. Most of my TRICARE patients havethe mindset, “If I can’t get it for free (or very cheap), I don’t want it.” I try toprescribe the best and safest medicine, which at times means it is moreexpensive. I would like to see doing away with blanket rejections and onerous obstacles. Instead, [I would like to see] a tiered system where thepatients can still get what is best and safest for them just by paying a bithigher co-pay. Then, I would have to do fewer unnecessary lab tests andadditional office visits, [and I would have] fewer hoops to jump through.
Bureaucrats don’t know why a certain medication is best for a certain patient.
They don’t know the long history of what has been tried and failed orassociated with side effects already. I do.
TRICARE Program
We are frustrated by TRICARE’s abysmal reimbursement. Most doctors inthis geographic area are not [TRICARE] providers because of this. We foughtwith TRICARE over depoprovera coverage. I have to buy 96 units of depo toget the lowest price of $41.20 each. TRICARE pays $45 plus $12 copay. Whatbusiness can survive with such a narrow profit margin? TRICARE is theworst payer for depoprovera. [TRICARE] used to pay $31 [each], and Ialmost dropped my provider status over this. I feel military personnel shouldget the drugs prescribed at no cost to them. When I was in active duty, Iserved in the P&T committee and we were responsive to patient needs andcosts; it worked well. But managed care P&T committees are dishonest, and Icannot deal with the myriad formularies shoved my way. I have never seen aTRICARE formulary.
It is very difficult to find specialists to refer our TRICARE patients to.
TRICARE takes a long time to approve our referrals. Of the hundreds ofinsurance companies we deal with in our office, TRICARE is by far the worstinsurance company.
I am a veteran. I have 3X years for pay purposes. I was a Navy corpsmanduring the Korean conflict, a Navy surgeon in Vietnam, and retired as an O-6chief of surgery. I was recalled (from retired status) for Desert Shield/DesertStorm for most of 1991. Losing my private practice in the process, I was incivilian practice from 197X-197X, 198X-199X and since the end of 199X. Ibelieve I’m in a position to judge, both from military and civilianstandpoints, comparative medical systems. TRICARE is an abomination;virtually no physicians will accept TRICARE Prime due to the extremely lowreimbursement rates. I haven’t received an updated provider’s directory inthree years. The personnel at the local office are unresponsive and oftenrude. The referral process is by far the most cumbersome. To my knowledge,there is no intermediary “representative” between TRICARE and physicians.
In brief, it is the worst third-party carrier with whom we deal.
Most parents do not go to military facilities for drugs because the waitingtime is too long, and when you have a sick child, you want to start treatmentASAP.
I am very unhappy with the fact that the military base does not provide acopy of a formulary. I cannot prescribe medications on the formulary if I donot have knowledge of what is on the formulary! Furthermore, it is almostimpossible to get any help by phoning them. They will not allow refills byphone or fax like real pharmacies. My patients are very upset when theydrive 30-plus miles to the base to fill a prescription and are told that theprescription is not on their formulary. In my opinion it is a poor excuse for apharmacy but I guess that the price is right! It is difficult to keep up with all the insurance companies’ formularies. Ialways ask my patients if they know if a certain medication is available at[the MTF]. I do sign all of my prescriptions on the “product selectionpermitted” side [of the prescription form]; however, this seems unacceptableat the [MTF]. By signing this, it should allow the pharmacist to make thesubstitution. I don’t have this problem with commercial pharmacies. Wehave more problems with TRICARE referrals than with the formulary.
TRICARE provides poor coverage compared with other providers.
I suppose formularies are a necessary evil to contain costs. I find them,however, to be extremely burdensome. Most of my TRICARE patients havethe mind-set, “If I can’t get it for free (or very cheap), I don’t want it.” I try toprescribe the best and safest medicine, which at times means it is moreexpensive. I would like to see doing away with blanket rejections andonerous obstacles. Instead, [I would like to see] a tiered system where thepatients can still get what is best and safest for them just by paying a bithigher co-pay. Then, I would have to do fewer unnecessary lab tests andadditional office visits, [and I would have] fewer hoops to jump through.
Bureaucrats don’t know why a certain medication is best for a certain patient.
They don’t know the long history of what has been tried and failed orassociated with side effects already. I do.
TRICARE management programs waste many hours of precious patient andstaff time (e.g., attempting to micromanage first- and second-order clinicaldecision-making processes and testing). We are in the process of consideringdropping this program because it [has a large] hassle factor and pre-approval, which wastes time, money, and efficiency. Actually[TRICARE’s]drug program, which is full of micro-management holes, isbetter than their medical decision and pre-approval program—you shouldhave run a survey for that! Communication
The formularies or preferred drug lists need to be in an easy-to-use formatand on the Net or available through touch-tone phone—[then one could]spell out the medication to see if [it is] approved.
Patients need to be educated as to (a) why they have a formulary and (b) whatthe cost of their medications is. They are currently too removed from the truecost of their health care, including drug costs.
Provide the patient with a list of formulary alternatives for their problem.
Justify formulary rejection to the provider and patient. Miscellaneous
I notice that my TRICARE patients are very well behaved and respectfulcompared with their peers—God Bless Our Military! Each health insurance product has a different formulary or preferred druglist and process for approving non-included medications. It is impossible foranyone to keep these lists current. If everything is equal, I will try toprescribe the covered or less-expensive drug, but often there are small butimportant differences [that would warrant prescribing] other medications. Ifthe pharmacist or patient approached me regarding the alternative, I wouldbe able to explain the reason for the choice. Systems that increasepaperwork/staff time and patient activities decrease the use of neededmedications, [but there] is still increased cost for health care [at a non-pharmacy level].
I am retired from the Army, and even when I was on active duty I wasunable to get a copy of the mail order formulary. I do keep copies of localmilitary formularies when available but would love a copy of the mail orderformulary and its prescribing rules. Thanks.
The problem is taking the time to look up a patient’s drug in all the differentformularies we have to keep up with.
The field of neurology—especially in epilepsy treatment—is changingrapidly. I do not feel that a formulary can keep up with rapidly evolvingpharmacopeae.
I am usually not aware of the type of insurance my patient has.
Occasionally patients will say they’re from the military base and are going totheir pharmacy there. However, they have not mentioned any restrictionswith formulary medicines.
Military people and dependents deserve the best medical care for the jobthey do. They work in bad weather conditions, under lots of stress, andsometimes risk their lives for their country! Thanks.
I have only had one military personnel patient, and he has moved out oftown. I hate formularies. I have enough to do to practice medicine withoutthe added burden of consulting formularies. I routinely throw awayformularies! There are too many different formularies for different insurance companies.

Source: http://www.prgs.edu/content/dam/rand/pubs/monograph_reports/MR1615/MR1615.appe.pdf