Tricare beneficiaries will soon pay more for some diagnostic genetic tests ordered by their civilian physicians – including procedures used to detect cystic fibrosis or determine cancer treatments – if the Defense Health Agency deems them to be medically unnecessary.
Stars and Stripes is reporting Tricare stopped reimbursing clinical laboratories in January 2013 for more than 100 different genetic or molecular pathology tests. The laboratories impacted by the changes are now providing the tests at no charge with that bill reaching about $10 million to date.
“That’s obviously unsustainable,” said Julie Khani, vice president of American Clinical Laboratory Association.
The costs of the tests, Khani said, can range from $60 to more than $1,000 and that bill will now go to the Tricare user.
Among the tests that are no longer covered are prenatal tests to identify if a pregnant woman is a carrier for the cystic fibrosis marker. “It’s covered by Medicaid and other commercial health plans. It is also the standard of care under VA-DOD clinical practice guidelines for management of pregnancy,” Khani said.
Tricare is still covering the costs of diagnostic genetic testing performed at Military Treatment Facilities or MTFs.
The Military Coalition, a consortium of military and veterans organizations, said the denial of payment for tests ordered by civilian physicians “creates two standards of care.”
“Beneficiaries who receive their healthcare at an MTF are covered for (tests), while beneficiaries who access care in the civilian provider network are denied coverage for these valuable diagnostic tests,” the coalition wrote in a Jan. 9 letter to Dr. Jonathan Woodson, Assistant Secretary of Defense for Health Affairs. “Tricare beneficiaries without access to MTS are relegated to second-class healthcare.”
The coalition called on DOD to restore the services quickly.
“We urge the (DOD) to provide equal access to high quality, needed healthcare services,” they wrote.
The testing reimbursement change isn’t the only new Tricare procedure. Starting Feb. 14, 2014 military retirees and family members who use Tricare for Life will be required to fill long-term prescriptions by mail.
The change applies only to Tricare users age 65 and older and is for maintenance medications. Medications needed for acute illnesses, as well as prescriptions covered by other health plans, will not have to be ordered through the mail.
According to Marine Times, the Department of Defense determined nearly half the 70 million prescriptions filled for Tricare beneficiaries at retail pharmacies were for Tricare for Life beneficiaries. Those prescriptions cost the government about $2.2 billion in 2012.
DOD pays 17 percent less for maintenance medication filled by mail compared to those filled at retail stores and the change could save the Pentagon as much as $120 million a year. It will also save Tricare for Life users: a 90 day refill of a generic medication cost nothing if delivered via the mail but requires a $5 co-pay for a 30-day prescription at a retail store. Brand name drugs cost $13 for 90-day prescription by mail but $17 for a 30-day prescription at a store.
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