Points of Interest: Pharmacy Users Confused by Maze of Restrictions

By Tom Philpott

Hunter's experience hints at the confusion surrounding pharmacy policy as hospitals take different actions to control pharmacy budgets. Dr. Edward D. Martin, acting Assistant Secretary for Health Affairs since Joseph's 1 April retirement, conceded in an interview that many hospitals have set improper restrictions on the pharmacy benefit.

Some refuse to dispense certain drugs, even from the hospital formulary, for prescriptions written by civilian rather than military specialists. Some deny medications to persons residing outside the hospital's 40-mile "catchment" area. Both rules violate policy, Martin said. "I expect them to stop," he said. "I sent the word down. I have spoken to the three surgeons general."

When hospitals refuse to fill prescriptions not written by a military specialist, beneficiaries face a classic Catch-22 situation. On paper, they have a pharmacy benefit; in reality, many can't be seen by a military doctor to obtain the free medication. Kristen Glackmeyer, a registered nurse and wife of a retired soldier, said this occurs at Womack Army Hospital, Fort Bragg, North Carolina. A local civilian oncologist that Glackmeyer works for recently prescribed Neupogen for a retiree to control his white blood count during chemotherapy. Neupogen is on Womack's formulary, but only for prescriptions written by Womack specialists.

Retired Air Force Major Lloyd Teale, 71, said Madigan Army Medical Center, Fort Lewis, Washington, won't fill his prescription for Norvasc, a blood pressure medication that appears on Madigan's "restricted" formulary. Teale, now eligible for Medicare, can no longer get into Madigan. But cardiologists there routinely prescribe Norvasc for other heart patients.

Martin said hospitals can require that prescriptions for certain drugs be written by specialists rather than general practitioners. But they cannot refuse to fill prescriptions because a specialist happens to be a civilian.

"If you've got a drug on the formulary and you're not filling it because it's a civilian provider, that's unacceptable," he said. "If you're not filling it because beneficiaries don't live in the catchment area, that's outside the policy. If it's on the formulary and you give it to active duty but don't give it to non-active duty, that's unacceptable."

Martin understands why hospital commanders have tried to tighten access to drugs. "Over the last year," he said, "pharmacy budgets have been skyrocketing."

Drug manufacturers kept prices in check during the debate over national health care. With that issue now dormant, drug pricing and marketing have become "much more aggressive," he said. Doctors are writing more prescriptions, drugs are more costly, and more patients turn to the military to have them filled for free.

Martin expects some military hospitals to run out of drug dollars by August—two months before the budget year ends. If so, and extra money can't be found elsewhere, Martin said he will seek supplemental funding from Congress.

Budget pressures from pharmaceuticals are building throughout the health care industry, Martin said. "I'll bet you within the next 3-6 months, you will begin to see feature articles on pharmacy costs out of control," he predicted.

"If you listen, you can hear the tsunami on its way. It's coming. It hit us first [because] there's a [more direct] relationship between us and our beneficiaries," Martin said. But everyone in managed care or traditional health insurance plan can expect to see co-payments and deductibles rise to cover higher drug costs, he said.

Martin already has decided to move toward a single formulary for all hospitals. Each facility now builds its own formulary around a core of drugs mandated by Defense. But too many differences between local formularies are causing "portability" problems for patients moving between hospitals or to new assignments, Martin said.

As a first step toward a "consistent formulary," Martin wants a single list of drugs adopted soon for seven military hospitals in the Washington, D.C., area.

Hunter, meanwhile, stops by the Eglin pharmacy on occasion for other medicines and checks on the Lamisil. It's still on the shelf, still out of Hunter's reach.


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