On July 17, Nexium, a heavily marketed drug used to treat acid reflux and peptic ulcers, was bumped off the military’s uniform formulary, as were Teveten and Teveten HCT, two drugs to treat high blood pressure. Next to go likely will be two popular pills to treat impotency - Viagra and Cialis - as well as five antifungal products.

The shaping of the military uniform drug formulary is under way. It’s a deliberate process that beneficiaries can follow online at http://www.tricare.osd.mil/pharmacy/pt_cmte/
Congress directed DoD to develop a single drug formulary across all points of service: base pharmacies, TRICARE retail network, and mail order. The goal is not to deny needed medicines, but to encourage beneficiaries and their doctors to ignore drug industry hype and select medicines that are both clinically effective and cost-effective.

DoD’s Pharmacy and Therapeutics (P&T) Committee, comprising of senior physicians and pharmacists, is reviewing drugs by class and studying the clinical data, safety records, and cost. If all drugs in a class are found equally effective in treating an illness, and side effects are comparable, the formulary choice likely will swing on the cost of stocking the drugs. If price is not competitive, the committee suggests moving a drug off the formulary.

Non-formulary drugs cannot be dispensed on base unless the prescribing physician claims medical necessity. They remain available by mail order or through the retail network but for a higher copayment of $22.

The three price “tiers” are, for mail order, $3 for a 90-day supply of a generic drug, $9 for a formulary drug, and $22 for non-formulary. The same tiers exist for the retail network but cover only a 30-day supply.

To ensure a voice for beneficiaries in the process, DoD officials established a Beneficiary Advisory Panel (BAP) with representatives from military associations, John Class, deputy director of MOAA’s Government Relations Department, and a few doctors and pharmacy experts. At each BAP meeting, fresh P&T recommendations are presented, discussed, and voted on. The BAP votes are advisory only. Panelists concur or non-concur on recommendations to move drugs off the formulary and also vote on how quickly that should occur.

Both the P&T report and the BAP’s advice then are presented to Dr. William Winkenwerder, assistant secretary of defense for health affairs, who makes final decisions on shaping the formulary.

The highlight of the June 27 BAP meeting in Washington D.C., wasa discussion of P&T findings regarding Viagra, Cialis, and Levitra, described as “old standard” treatments for erectile dysfunction (ED). None was found to be more clinically effective. Levitra, however, is less costly to stock.

Viagra is prescribed for 77 percent of military beneficiaries taking impotency medicine - 13 percent use Cialis and only 10 percent Levitra.

To save DoD an estimated $13 million a year, the P&T Committee recommended that Viagra and Cialis lose formulary status. The decision would affect 128,000 beneficiaries. Letters from two of them were read aloud to the BAP panel. A retired 30-year Marine with prostate cancer attributed to exposure to the defoliant Agent Orange said he and other members of his cancer support group use Viagra and “swear by this great product.” He asked that it not be dropped from the formulary.

A Navy retiree wrote that he used Viagra and so did his son, a Naval Reserve pilot and Iraqi Freedom veteran recovering from testicular cancer.

“To deny him and other U.S. armed forces personnel and veterans like myself with [ED] would be a tragedy and could have a negative impact on their sexual relations and morale,” the retiree warned.

Citing one of the letters, BAP panelist Dr. Jeffrey L. Lenow, with Jefferson Medical College in Philadelphia, noted that there can be both a physical and a psychological basis for impotency. Even if clinical tests suggest two drugs are equally effective, that might not be true for individual patients. He hoped, Lenow said, that the P&T Committee consulted outside psychologists on “the collateral impact of a decision like this.”
P&T Committee reps advised the BAP that if Levitra doesn’t work for a particular patient, his doctor can argue medical necessity and Viagra or Cialis still can be made available for free on base or for the current $9 copayment in the network or by mail order.
If only 15 percent of ED patients switch to Levitra, the formulary change still will be cost effective, said Air Force Maj. Wade Fuller, a P&T pharmacist in charge of economic analysis. However, an 80 percent shift to Levitra is presumed.

Four out of eight BAP panelists concurred with the P&T recommendation. Winkenwerder was expected to endorse it by mid-July and to direct that only Levitra remain on the formulary, to take effect either in 90 or 120 days.

The next BAP meeting, in September, will review fresh P&T findings on several more classes of drugs.

Tom Philpott is a freelance writer and syndicated news columnist. His column, "Military Update," appears in 48 daily newspapers throughout the United States and overseas.