Budget tightening leads to drug changes

By Tom Philpott: Military Update

Phyllis Ramm, wife of an Air Force retiree, got a surprise Aug. 7 when she called the Keesler Air Force Base pharmacy to refill routine prescriptions.
She learned that some popular brand-name drugs no longer would be dispensed on base, after patients get a final 30-day supply.
The Air Force directed its 74 pharmacies in July to drop Allegra, for allergy relief, and Celebrex, for arthritis pain, from their formulary, and to recommend instead lower-cost alternatives of equal effectiveness.
Patients using Allegra, a non-drowsy antihistamine, can take a generic form of Claritin instead, said Maj. Gen. Joseph E. Kelley, Air Force assistant surgeon general, in a July memo to commands.
Users of Celebrex and Bextra, “cox-2 inhibitors” for arthritis, should switch to Vioxx. Patients using the insulin Humalog should be offered Novolog instead.
The changes, meant to control spiraling drug costs without sacrificing patient care, reflect “an extremely challenging budget year for the Air Force Medical Service,” Kelley said.
The change also upset some patients including, Phyllis Ramm’s husband.
“My feeling is that our entitlement, of which pharmaceutical service is a part, is being chipped away,” said retired Chief Master Sgt. Charles Ramm, a resident of Gautier, Miss.
Air Force pharmacies are only the first to tighten drug inventories in this way. The Army and Navy are expected to make similar moves this fall, during a more formal process to shape a Uniform Formulary.
Cmdr. Leisa Richardson, with the Navy pharmacy directorate, said her service developed the changes adopted by the Air Force.
“We would like to see these cost-savings initiatives become tri-service,” she said.
“Frankly, the Air Force kind of caught us all flat-footed,” said another service official.
The Air Force needed to act to control costs, said Col. Phil Samples, pharmacy consultant to the Air Force surgeon general. Though the service has known since last October that its wartime medical budget for 2004 was tight, costs are rising faster than expected. Air Force base pharmacy costs on its 100 most popular drugs is up a projected $38.3 million over last year, and not all of that is budgeted, Samples said.
Lt. Col. David Bobb, deputy to the surgeon general for medical support, operations and policy, said the Air Force tightened drug formularies only after reducing spending on medical equipment and supplies, and found that wasn’t enough. Remaining choices were few, he suggested.
“We certainly don’t want to have to close up any facilities before the end of the fiscal year,” Bobb said.
The decision drew criticism from service associations and veteran groups who expect to have a formal role, starting this fall, in developing a uniform formulary for drugs offered through TRICARE retail outlets and the TRICARE mail order program.
A new Department of Defense Pharmacy and Therapeutics (P&T) Committee, comprised of physicians and drug experts from DoD and the services, will begin in September to review drugs for efficacy and cost.
Medicines on the uniform formulary should continue to be available on many bases at no charge. But their availability will be guaranteed in TRICARE retail network and by mail order for a co-payment of $3 for generic and $9 for brand name drugs.
Drugs designated “non-formulary‚” a new third tier of the benefit, will not be available on base, and the cost per prescription will be set at $22.
Given the Air Force moves in July, Allegra and Celebrex are likely non-formulary candidates.
P&T Committee decisions will be reviewed by a Beneficiary Advisory Panel, to include representatives of active duty families and retirees. Dr. William Winkenwerder, assistant secretary of defense for health affairs, will review all comments and make final formulary decisions as they arise.
Bob Washington of the Fleet Reserve Association, who will serve on the beneficiary panel, said the Air Force’s change in base formulary last month looks like an attempt to “circumvent” this process.
Air Force officials said they worried about that perception but still needed to act.

Tom Philpott can be contacted at Military Update, P.O. Box 231111, Centreville, Va. 20120-1111, or by e-mail at:
milupdate@aol.com