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Highlights

What GAO Found

For covered brand maintenance medications—those medications that are taken on a regular and recurring basis—the Department of Defense (DOD) has not fully monitored availability or the timeliness and accuracy of prescriptions filled for the TRICARE for Life Pharmacy Pilot. Specifically, GAO found that for the

mail-order program: DOD has monitored the availability of medications. It has also established and monitored performance standards on the timeliness and accuracy of prescriptions filled through mail order for all of TRICARE, but has not separately monitored performance through mail order for the pilot.

military-treatment-facility (MTF) pharmacies: DOD has not established or systematically monitored performance standards for the pilot on the availability of covered medications, or the timeliness and accuracy of prescriptions filled across MTF pharmacies.

Federal internal control standards suggest that agencies establish and review performance standards and monitor performance data to assess the quality of performance over time. Without fully monitoring the pilot's performance, DOD does not know whether it is working as intended, information that would be beneficial given the upcoming expansion of its requirements to all eligible TRICARE beneficiaries.

DOD has not monitored the extent to which beneficiaries were satisfied with the transfer of prescriptions to mail order or MTF pharmacies for the pilot. DOD officials said they relied on the results from a quarterly survey of TRICARE mail-order users to assess the satisfaction of pilot beneficiaries. However, other DOD officials who monitor the survey data said they do not know how representative the respondents are of pilot beneficiaries making the use of these data for this purpose questionable. Moreover, DOD has not monitored satisfaction of pilot beneficiaries across MTF pharmacies. Federal internal control standards require agencies to obtain information from external stakeholders to assess if they are achieving their goals, and to monitor and assess the quality of performance over time to ensure that issues are resolved. Without this stakeholder input, DOD lacks important information as to whether pilot beneficiaries faced any difficulties, including with obtaining their medications.

DOD appears to have achieved its expected cost savings based on estimates GAO reviewed. For the first year of the pilot, DOD's estimated cost savings were approximately $123 million based on the prescriptions for covered medications filled through mail order. This was comparable to DOD's projected cost savings of $120 million, an estimate that DOD developed prior to the start of the pilot.

DOD has issued regulations, but not finalized planning documents for the expansion of the pilot requirements. Officials said that they are in the process of developing planning documents, which will generally model those that were developed for the pilot. Given the limited monitoring conducted during the pilot, as it finalizes its planning documents for the expansion of the pilot to all eligible TRICARE beneficiaries, DOD would benefit from developing a robust monitoring process of affected beneficiaries, including the availability of medications, the timeliness and accuracy of prescriptions filled, and beneficiary satisfaction.

Why GAO Did This Study

DOD offers a pharmacy benefit to TRICARE beneficiaries who may obtain prescriptions from TRICARE's mail-order program, MTF pharmacies, or retail pharmacies. In 2013, the DOD Inspector General reported it was more cost efficient to fill prescriptions through mail order than retail pharmacies. To reduce costs, the National Defense Authorization Act (NDAA) for Fiscal Year 2013 required DOD to implement a pilot for certain TRICARE beneficiaries to obtain covered brand maintenance medications through mail order or MTF pharmacies. Under NDAA 2015, the pilot terminates at the end of fiscal year 2015, after which the pilot requirements are to be expanded to all eligible TRICARE beneficiaries.

The NDAA 2015 included a provision for GAO to examine the pilot. This report examines the extent to which DOD has (1) monitored whether covered brand maintenance medications were available, and prescriptions were filled on time and accurately, (2) monitored the satisfaction of participating beneficiaries, (3) achieved expected cost savings, and (4) prepared for the expansion. GAO reviewed and analyzed pilot performance and beneficiary satisfaction data, and cost savings estimates, and interviewed DOD officials and other stakeholders.

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Recommendations

GAO recommends that DOD develop a monitoring plan as part of its expansion planning documents. DOD concurred with GAO's recommendation.

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Defense 1. To be able to identify and address problems that may occur and thus help ensure a smooth transition, the Secretary of Defense should require the Defense Health Agency ensure that planning documents for the expansion include specific requirements to continuously monitor affected beneficiaries, including whether (1) covered medications are available and filled in a timely and accurate manner through mail order and across MTF pharmacies; and (2) beneficiaries are satisfied with the transition to mail order and MTF pharmacies.
Closed - Implemented
At the time of the report, DOD concurred with our recommendation and has taken the following steps: In response to the recommendation that DOD monitor beneficiary satisfaction, DOD fielded a satisfaction survey starting in 2017. The survey was twice administered-once in August 2017 and again in February 2108-to a sample of the beneficiaries over the age 65 that moved their prescriptions from a retail pharmacy to a Military Treatment Facility (MTF) pharmacy. In 2018, DOD expanded the pharmacy program to all TRICARE beneficiaries. DOD administered two additional satisfaction surveys in August 2018 and February 2019 to a sample of all beneficiaries that moved their prescription from a retail pharmacy to a MTF pharmacy. Most of the beneficiaries surveyed were satisfied with the availability, timeliness, and accuracy of prescriptions filled at MTFs. In June 2019, DOD officials told us that they intend to continue conducting the satisfaction survey. Regarding monitoring availability, timeliness, and accuracy of prescription filled through mail order and across MTF pharmacies, DOD tracks the availability, timeliness, and accuracy of prescriptions filled through TRICARE's mail order program. While DOD did not separately tracked these data for beneficiaries who transitioned from retail to mail order, these beneficiaries have been using the mail order program for about 4 years since the transition began in October 2015 and DOD's monitoring of all mail order users is sufficient. In June 2019, DOD officials told us that the Defense Health Agency (DHA) does not have a standardized mechanism to track timeliness, accuracy, and availability of prescription drugs across all of the MTFs and that tracking these elements is a function that is managed independently by each of the military services. DOD officials stated that they would use the satisfaction survey as means of monitoring timeliness, availability, and accuracy of filling prescriptions across MTFs.

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