When Congress passed the National Defense Authorization Act for Fiscal Year 2018 (NDAA), they gave the Department of Defense (DoD) new authority to exclude medications from TRICARE’s formulary. Following this, the agency took steps to exclude specific pancreatic enzyme replacement therapies (PERTs) from TRICARE’s formulary, which would prevent servicemembers from receiving coverage for them.
PERTs are medications that address exocrine pancreatic insufficiency (EPI), which occurs when the pancreas does not produce enough digestive enzymes to properly absorb nutrients from food. EPI is caused by other conditions that affect the pancreas, such as cystic fibrosis, chronic pancreatitis, and pancreatic cancer. Without access to PERTs, patients with EPI will likely experience digestive complications, including diarrhea, steatorrhea, uncontrollable weight loss, stomach pain, and vitamin deficiencies. Having access to a broad selection of PERT options is beneficial for patients with EPI, as each product has a unique formulation and dosage. If a patient is stable on one of these treatments and they lose access to it, they will likely experience negative health consequences and lower quality of life as they try to find another treatment that works for them.
After DoD recommended that a PERT option be removed from TRICARE’s formulary, the Director of TRICARE rejected the recommendation. Aimed Alliance sent a letter to TRICARE’s Director, Vice Admiral Bono, expressing gratitude for rejecting the recommendation to exclude coverage of a PERT option. We emphasized the need for patients to remain stable on their current medication and recommended that the agency remove step therapy restrictions for this entire class of medications to help patients access the option that works best for them.