Tricare questions five-year-old prescriptions, claws back money from compounding pharmacists

In 2015, compounding pharmacies across the country processed thousands of legitimate, legal prescriptions for veterans and servicemen and -women. Now, with no evidence, Tricare claims that the physicians didn’t have a relationship with those patients — but it’s making the pharmacies pay.

Tricare questions five-year-old prescriptions, claws back money from compounding pharmacists

In 2015, compounding pharmacies across the country processed thousands of legitimate, legal prescriptions for veterans and servicemen and -women. Now, with no evidence, Tricare claims that the physicians didn’t have a relationship with those patients — and it’s making the pharmacies pay.

Starting in early June, compounding pharmacies around the country began receiving letters from Express Scripts, the PBM that handles prescription benefits for Tricare, the U.S. military’s health insurer.

The letters claim that five years ago, some prescriptions for compounded drugs filled by these pharmacies came from physicians who didn’t actually meet their patients in person before writing the prescription. (Tricare admits there is no proof of this, by the way, only suspicion.)

The prescriptions were perfectly valid, signed by a real physician, often one known by the pharmacist. They weren’t for controlled substances like opioids. They were for commonly used compounded medications. There was no reason for pharmacists to question them; they fill thousands of prescriptions for veterans and military personnel every month.

There isn’t even a space on a prescription for “How did you see the patient?” It’s a physician’s decision whether to meet physically, virtually, or over the phone, and never have pharmacists been asked to consider that, for good reason. Can you imagine the delays if pharmacists had to manually verify the circumstances of every prescription?

Yet somehow Tricare and Express Scripts are saying that compounding pharmacists should have checked the back story of every patient that came to them. “Outrageous” doesn’t even begin to describe that position.

So now, five years later, Tricare is not only demanding its money back, it’s authorized Express Scripts to take it — to claw it back before the pharmacists can even put together an appeal.


Without a time machine, that’s impossible; there is no way pharmacists can produce records they were never required to keep.


And yes, they can request an “administrative claims review.” They were given 90 days to prove that every one of these 2015 prescriptions came from a doctor who saw a patient face to face. And what’s considered proof? The physician’s word isn’t good enough; Tricare wants actual chart notes from the patient’s visit, which of course aren’t available to the pharmacy.

Without a time machine, that’s impossible. There is no way pharmacists can produce records they were never required to keep. The alternative is to try to contact every one of the hundreds or thousands of physicians who wrote those prescriptions in 2015 and hope they remember, if they haven’t moved or retired.

Tricare and Express Scripts have put compounding pharmacies in an untenable position: They are presumed guilty until they can prove themselves innocent of a nebulous offense they’ve never been responsible for.

These egregious clawbacks need to be reversed, immediately. A quick, unscientific survey of a small group of compounders shows the average clawback to be about $26,000 — money that, especially in this economy, neighborhood compounding pharmacies simply can’t afford to pay. If Tricare believes these physicians acted improperly, it seems obvious that they’re the ones who should be receiving letters.

Finally, without protection for the future, these pharmacies have few options: They can consider refusing Tricare prescriptions out of fear of having them questioned in half a decade. (That would risk violating their Express Scripts contracts.) Or they can manually verify each Tricare prescription by playing phone tag with the prescriber, thus delaying their patients’ care.

They shouldn’t be required to make that choice at all.