Just a few days before coverage for weight-loss drugs is set to end for Tricare for Life beneficiaries, advocates are calling on the Defense Health Agency and lawmakers to halt those plans.
A new policy takes effect Aug. 31 for Wegovy, Zepbound, Saxenda, Qsymia, Phentermine and Contrave, affecting coverage of those drugs for weight-loss purposes. Tricare for Life is the Tricare plan for Medicare-eligible military retirees and their Medicare-eligible family members.
Defense Health Agency officials, in a response to Military Times, contended the change corrects unauthorized coverage that Tricare has been providing to beneficiaries who weren’t eligible for the weight-loss medications.
Tricare will continue to cover those weight-loss medications for younger beneficiaries — those enrolled in Tricare Prime or Tricare Select or premium-based plans. Those beneficiaries still must have prior authorizations for the weight-loss drugs. They must also meet Tricare’s clinical criteria and have a prescription from a Tricare network provider.
The premium-based plans include Tricare Young Adult, Tricare Reserve Select, Tricare Retired Reserve and Continued Health Care Benefit Program.
Current plans to end this coverage “risk the progress made by patients taking these medications and cast doubt on the future of the [Tricare for Life] benefit,” wrote Karen Ruedisueli, director of health affairs in government relations for the Military Officers Association of America, on the nonprofit organization’s website.
She said MOAA has sent an email to DHA officials expressing their concerns, and she noted they’re getting considerable feedback from their members.
The issue of coverage of weight-loss medications has a complicated regulatory and legislative history with conflicting guidance, she said. Thus, “halting this policy change would provide time to assess the legislative and regulatory history governing Tricare policy on weight loss medications and determine next steps to avert negative impacts to beneficiaries,” she wrote in the article calling for a halt in the plans.
In an Aug. 5 press release that included information about the change, Tricare officials said the Defense Health Agency is “implementing regulatory controls” on weight-loss medication coverage.
“Tricare has been providing coverage for weight loss medications to beneficiaries who were not eligible under federal statute. This implementation corrects that unauthorized coverage,” DHA spokesperson Brenda Campbell said in an email response to Military Times’ questions about the reasons for ending the coverage.
She noted that different laws govern Tricare Prime and Tricare Select.
“These laws allow DOD to offer certain health care services and health benefits when received from network providers under those plan options that are not available to [Tricare for Life] beneficiaries,” Campbell said. “Some Tricare for Life beneficiaries were found to have received coverage for these medications inconsistent with existing statutory and regulatory authority.”
In the Aug. 5 announcement of the change, Defense Health Agency Chief Medical Officer Dr. Paul Cordts said “people are taking GLP-1 drugs — like Wegovy and Zepbound — for weight loss now more than ever. It’s important to understand how — and why — Tricare covers these drugs, based on your condition and status.”
In an email to Military Times, one Tricare for Life beneficiary prescribed Wegovy said she feels as if Tricare officials “are saying we are subpar members, not as worthy as the Prime or Select members.”
“Wegovy has been a miracle for my medical conditions of obesity, metabolic syndrome, pre-diabetes, pre-hypertension, sleep apnea,” she added. “All of that improved with this medication. Now they just cut it off.”
The letter she received from Tricare stated she could continue filling her current prescription — and pay 100% of the drug cost. That amounts to $1,300 per month.
“That will take most of our retirement money,” she said.
GLP-1 drugs approved by the Food and Drug Administration for the treatment of diabetes will continue to be covered for all patients who have a diabetes diagnosis, when medically necessary and when prior authorization requirements are met, according to Tricare officials.
Tricare covers Trulicity, Ozempic, Mounjaro and Victoza to treat type 2 diabetes, with prior authorization. Ozempic, Mounjaro and Victoza require medical necessity forms for a formulary copayment and coverage at a military pharmacy, officials stated.
Since the change in coverage was announced, MOAA has received a considerable amount of feedback from its members, all of whom went through extensive prior authorization processes to document co-morbid conditions, lifestyle changes and trials of alternative medications before they met the clinical criteria for approval for the weight-loss medications, Ruedisueli wrote, adding that Tricare doesn’t cover these drugs for cosmetic purposes.
The members are worried their progress will be reversed if they can no longer use these drugs.
“A physician from Walter Reed National Military Medical Center also reached out to MOAA with concerns about the new policy and its impact on Walter Reed’s military retiree patients,” Ruedisueli wrote.
And members who aren’t directly affected have another concern: that the change represents a terrible precedent and could lead to further targeted cuts to Tricare for Life. MOAA shares that concern, Ruedisueli wrote.
Officials are urging beneficiaries to talk to their health care providers about their options and suggest using the Tricare Formulary Search Tool to check costs and coverage requirements.
Karen has covered military families, quality of life and consumer issues for Military Times for more than 30 years, and is co-author of a chapter on media coverage of military families in the book “A Battle Plan for Supporting Military Families.” She previously worked for newspapers in Guam, Norfolk, Jacksonville, Fla., and Athens, Ga.
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