DOD AND VA 

HEALTH CARE

Medication Needs 

during Transitions 

May Not Be Managed 

for All 

Servicemembers 

Report to the Ranking Member, 

Committee on Veterans’ Affairs, 

House of Representatives

November 2012

GAO-13-26

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United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-13-26, a report to the 

Ranking Member, Committee on Veterans’ 

Affairs, House of Representatives

November 2012

DOD AND VA HEALTH CARE

Medication Needs during Transitions May Not Be 

Managed for All Servicemembers 

Why GAO Did This Study

Medication management is critical to 

effective continuity of care for 

servicemembers transitioning out of 

the military. Psychiatric and pain 

medications may be of particular 

concern because of potential adverse 

health effects if not taken as intended. 

GAO was asked to provide information 

on the process used by DOD and VA 

to help servicemembers manage their 

psychiatric and pain medications 

during transitions. In this report, GAO 

examined (1) the extent to which 

servicemembers transitioned out of the 

DOD health care system with 

psychiatric or pain medications and 

subsequently received care from VA 

and (2) efforts DOD and VA have in 

place to help ensure servicemembers’ 

psychiatric and pain medication needs 

are met during transitions of care. GAO 

focused on active duty 

servicemembers, Reservists, and 

National Guard members who 

discharged from military service and 

Reservists and National Guard 

members who demobilized in fiscal 

years 2009 through 2011. GAO also 

reviewed DOD and VA documents, 

including transition policies, and 

interviewed DOD and VA officials from 

headquarters and six DOD and VA 

facilities, selected on the basis of size, 

geographic location, patient 

characteristics, and other factors.

What GAO Recommends

GAO recommends that DOD develop a 

transition policy for medications that 

applies to all servicemembers and that 

DOD and VA identify and apply best 

practices for managing 

servicemembers’ medication needs 

during transitions of care. DOD and VA 

concurred with the recommendations.

What GAO Found

About 1 in 12 (approximately 94,000) servicemembers discharged from military 

service and Reservists and National Guard members demobilized in fiscal years 

2009 through 2011 had a psychiatric or pain medication, and almost half of these 

servicemembers subsequently received care from the Department of Veterans 

Affairs (VA) within 9 months. The percentage of servicemembers discharged or 

demobilized with psychiatric or pain medications increased slightly across the 

3 fiscal years, from about 7 percent in fiscal year 2009 to about 9 percent in fiscal 

year 2011. The most common psychiatric medications for servicemembers 

discharged or demobilized from fiscal years 2009 through 2011 included 

antidepressants, while the most common pain medications included nonsteroidal 

anti-inflammatories, such as prescription-strength ibuprofen, and an opioid—

oxycodone acetaminophen. Although not all discharged or demobilized 

servicemembers receive care from VA, GAO found that almost half of 

servicemembers with psychiatric or pain medications in fiscal years 2009 through 

2011 subsequently received care from VA within 9 months.

The Department of Defense’s (DOD) and VA’s efforts may not help all 

servicemembers manage their medication needs during transitions of care. DOD 

does not have a formal policy for transitioning medication needs for all 

servicemembers, and the efforts available to all servicemembers are limited. For 

example, DOD officials identified the medical assessment as the effort DOD has 

in place to help all servicemembers transition their medical needs prior to 

discharge. This assessment is a key opportunity for assisting all servicemembers 

with managing medications; however, DOD cannot ensure that certain best 

practices, such as developing a plan for how to obtain medications during the 

transition and providing current medication lists at the point of discharge, are 

included during these assessments. In addition to efforts that may assist all 

servicemembers, DOD and VA provide specific servicemember groups with more 

thorough and direct assistance in transitioning their health care, including 

medications. For example, servicemembers with complex health care needs may 

receive additional assistance through military case management services. 

Finally, some DOD military treatment facilities and VA medical centers have 

efforts that can help manage servicemembers’ medication needs, but these may 

not be available at all facilities. Many of the programs available only to specific 

groups or to servicemembers accessing certain DOD or VA facilities incorporate 

identified best practices for transitions of care, such as sharing medical 

information between providers, scheduling VA appointments and providing 

servicemembers with medication lists prior to discharge. Identifying best 

practices and implementing them across the departments could better ensure 

overall continuity of care, including medication management, for servicemembers 

transitioning between health care providers, and could reduce their potential for 

adverse health effects from misusing or discontinuing psychiatric or pain 

medications.

View GAO-13-26. For more information, 

contact Debra A. Draper at (202) 512-7114 or 

draperd@gao.gov.
Page i GAO-13-26 DOD and VA Health Care

Letter 1 

Background 5

About 1 in 12 Transitioning Servicemembers Had Psychiatric or 

Pain Medications; Almost Half Subsequently Received VA Care 11

DOD’s and VA’s Efforts May Not Help All Servicemembers Manage 

Their Medication Needs during Transitions of Care 14

Conclusions 27

Recommendations for Executive Action 28

Agency Comments and Our Evaluation 28

Appendix I Scope and Methodology 31

Appendix II Formulary Comparison 35

Appendix III Comments from the Department of Defense 43

Appendix IV Comments from the Department of Veterans Affairs 45

Appendix V GAO Contact and Staff Acknowledgments 49

Tables

Table 1: Servicemembers Discharged and Reservists and National 

Guard Members Demobilized with Psychiatric or Pain 

Medications, Fiscal Years 2009 through 2011 11

Table 2: Most Common Psychiatric and Pain Medications for 

Servicemembers Discharged and Reservists and National 

Guard Members Demobilized, Fiscal Years 2009 through 

2011 12

Table 3: Servicemembers Discharged and Reservists and National 

Guard Members Demobilized with Psychiatric or Pain 

Medications from Fiscal Years 2009 through 2011 Who 

Subsequently Received Care from VA 13

Contents
Page ii GAO-13-26 DOD and VA Health Care

Table 4: Comparison of DOD’s and VA’s Formularies for 

Psychiatric and Pain Medications, March 2012 37

Figures

Figure 1: DOD and VA Efforts Available to All Servicemembers 

That May Help Servicemembers Manage Their 

Medications during Transitions of Care 15

Figure 2: DOD and VA Efforts Targeted to Specific Servicemember 

Groups That Provide Additional Assistance to Help 

Manage Medication Needs during Transitions of Care 20

Abbreviations

DOD Department of Defense

OEF Operation Enduring Freedom

OIF Operation Iraqi Freedom

OND Operation New Dawn

PTSD post-traumatic stress disorder

VA Department of Veterans Affairs

WTU Warrior Transition Unit

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Page 1 GAO-13-26 DOD and VA Health Care

United States Government Accountability Office

Washington, DC 20548

November 2, 2012

The Honorable Bob Filner

Ranking Member

Committee on Veterans’ Affairs

House of Representatives

Dear Mr. Filner:

Medication management—ensuring that medications are used 

appropriately and regimens are adhered to—is critical to effective 

continuity of care for those servicemembers who are transitioning out of 

the military and changing health care providers. Management of 

psychiatric and pain medications may be of particular concern because of 

the prevalence of the conditions for which these medications are 

prescribed among servicemembers and the potential adverse health 

effects if not taken as intended. Literature indicates that between 20 and 

40 percent of servicemembers returning from Operation Enduring 

Freedom (OEF) and Operation Iraqi Freedom (OIF)1 suffer from 

deployment-related mental health conditions, including post-traumatic 

stress disorder (PTSD), depression, and substance abuse.2 Mental health 

conditions may be managed with various therapies, including 

medications, such as antidepressants and antianxiety medications. Pain 

is a serious and highly prevalent condition, according to a report from the 

Department of Veterans Affairs (VA) and the Department of Defense 

(DOD); among returning OEF/OIF servicemembers, pain is the most 

frequently presented complaint.3 Pain also may be managed with various 

therapies, including medications such as opioids.

 

1

Military operations in Iraq as of September 1, 2010, are referred to as Operation New 

Dawn (OND). 

2

See K. H. Seal et al., “VA Mental Health Services Utilization in Iraq and Afghanistan 

Veterans in the First Year of Receiving New Mental Health Diagnoses,” Journal of 

Traumatic Stress, vol. 23, no. 1 (2010). 

3

Department of Veterans Affairs and Department of Defense, VA/DOD Clinical Practice 

Guideline for Management of Opioid Therapy for Chronic Pain (May 2010). 

 
Page 2 GAO-13-26 DOD and VA Health Care

Individuals may experience serious adverse health effects when 

psychiatric and pain medications are abruptly discontinued. For example, 

when certain psychiatric medications are abruptly discontinued, an 

individual may experience problems such as relapses in psychotic 

episodes, return of anxiety symptoms, and exacerbation of depression 

symptoms. Similarly, when some pain medications, such as opioids, are 

not gradually reduced, an individual may experience withdrawal 

symptoms such as nausea, insomnia, and anxiety. Certain types of 

psychiatric and pain medications should be gradually tapered off under a 

doctor’s supervision.

The transition out of the DOD health care system, which can start when 

servicemembers discharge from the military and continue until they are 

cared for by receiving health care providers, such as VA, is a vulnerable 

point in terms of providing seamless care. Transitions between health 

care systems may increase the likelihood of patients deviating from their

treatment plans. Specifically, such transitions may increase the likelihood 

of patients discharged with medications not adhering to their medication 

regimens, for example by misusing or inappropriately discontinuing use of 

a medication their providers prescribed prior to discharge.

You expressed interest in obtaining information on the process used by 

DOD and VA to help servicemembers manage their psychiatric and pain 

medications during transitions from DOD to VA. In this report, we provide 

information on

1. the extent to which servicemembers transitioned out of the DOD 

health care system with psychiatric or pain medications and 

subsequently received care from VA and

2. the efforts DOD and VA have in place to help ensure 

servicemembers’ psychiatric and pain medication needs are met 

during transitions of care.

As requested, we also compared DOD’s and VA’s formularies for 

psychiatric and pain medications. (See app. II.)

To determine the extent to which servicemembers transitioned out of the 

DOD health care system with psychiatric or pain medications and 

subsequently received care from VA, we obtained data from DOD’s 
Page 3 GAO-13-26 DOD and VA Health Care

Defense Manpower Data Center and Defense Health Cost Assessment 

and Program Evaluation on the number of servicemembers who were 

discharged from military service4 and Reservists and National Guard 

members who were demobilized with psychiatric or pain medications 

(prescribed prior to discharge or demobilization) in fiscal years 2009, 

2010, and 2011.5

To identify the efforts DOD and VA have in place to help ensure 

servicemembers’ psychiatric and pain medication needs are met during 

transitions of care, we reviewed documents and interviewed officials from 

DOD, the Department of the Army,

In this report, we included servicemembers who 

discharged—active duty servicemembers, Reservists, and National 

Guard members—and Reservists and National Guard members who 

demobilized, because both of these populations can transition out of the 

DOD health care system and could be eligible for VA care. We then 

obtained data from VA’s National Data System on how many of these 

servicemembers subsequently received health care from VA within 

9 months of their discharge or demobilization date. We selected the 

9-month time frame to provide consistent data across each of the 3 fiscal 

years—the most current available VA data at the time of our review were 

from June 2012, 9 months after the end of fiscal year 2011. Data on 

servicemembers who subsequently received care from VA do not 

describe the full population of servicemembers who received care after 

being discharged from military service or demobilized as not all 

servicemembers subsequently seek and receive care from VA. We 

assessed the reliability of the data in several ways, including discussing 

with DOD and VA officials their methodology and data-collection 

techniques and conducting our own review of their programming and 

methodological approaches using data file documentation, code book and 

file dictionaries, and programming logs.

6

 

4

Servicemembers may discharge from the military under several circumstances, including 

expiration of term of service, medical retirement, and career retirement.

and VA. We reviewed documents, 

such as department policies related to health care and medication 

transitions. We interviewed officials from DOD, Army, and VA 

5

The number of servicemembers with pain or psychiatric medications is not equivalent to 

the number of servicemembers with related conditions because psychiatric and pain 

medications may be prescribed for other conditions.

6

We focused our review on the Army, rather than other military service branches, because 

the Army has the largest number of OEF/OIF/OND servicemembers.
Page 4 GAO-13-26 DOD and VA Health Care

headquarters offices that have oversight of, and set policies related to, 

the provision of health care, including psychiatric and pain care and 

prescription medication benefits, and that have roles in assisting 

servicemembers with their health care as they transition out of DOD. For 

example, we interviewed officials from DOD’s TRICARE Management

Activity’s Clinical Quality Office, Pharmacoeconomic Center, and Case 

Management Program; and the Office of the Surgeon General of the 

Army. We also interviewed officials from VA’s VA/DOD Collaboration 

Office and the Veterans Health Administration’s Pharmacy Benefits 

Management Services, Liaisons for Healthcare Program, and 

OEF/OIF/OND Care Management Program. In addition, we interviewed 

officials, including providers and case managers, from local Army military 

treatment facilities and VA medical centers, as well as servicemembers 

and veterans, through six site visits. We selected sites to visit to obtain a 

diverse sample on the basis of criteria such as facility size, patient 

complexity, presence or absence of a VA Liaison for Healthcare, and 

Army and VA region, and to ensure military treatment facility proximity to 

a VA medical center. On the basis of these criteria we selected the 

following facilities: (1) Walter Reed National Military Medical Center 

(Bethesda, Md.); (2) Washington D.C. VA Medical Center; (3) BayneJones Army Community Hospital (Fort Polk, La.); (4) Alexandria VA 

Medical Center (Pineville, La.); (5) Weed Army Community Hospital (Fort 

Irwin, Calif.); and (6) Loma Linda (Calif.) VA Medical Center. Finally, we 

interviewed officials from selected veterans service organizations—the 

American Legion, Military Officers Association of America, and Wounded 

Warrior Project—to obtain their perspectives on transition policies and 

programs.

We focused our review on efforts that department officials and local 

military treatment facility and VA medical center officials identified as 

having a role in helping servicemembers manage their medications as 

they transition from DOD to VA. We also focused on the transition efforts 

used by servicemembers transitioning between outpatient settings, rather 

than inpatient settings, because medication management between 

outpatient settings is a vulnerable point in terms of providing seamless 

care. The transition efforts we identified may not be exhaustive because 

some servicemembers may have received help through efforts that were 

not identified by the officials we interviewed or through efforts that may 

not have been related to the health care aspects of their transition. We 

did not review the effectiveness of the efforts identified.
Page 5 GAO-13-26 DOD and VA Health Care

Additionally, we reviewed relevant literature on transitions of care and 

medication adherence, including effective approaches for transitioning 

health care needs and strategies for promoting patient adherence to 

medication treatment plans. For example, we reviewed literature from the 

National Transitions of Care Coalition, a nonprofit organization that works 

to address gaps that affect safety and quality of care for transitioning 

patients, to identify best practices within DOD’s and VA’s transition 

efforts.

We conducted this performance audit from January 2012 to October 2012 

in accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives. See appendix I for a complete 

description of our scope and methodology.

DOD and VA provide health care, including medications for psychiatric 

and pain conditions, to servicemembers and veterans through their 

respective health care systems. Due to concerns about the continuity of 

care for servicemembers transitioning between the two health care 

systems, the departments have made efforts to coordinate transitions of 

care from DOD to VA. Medication management is a key component of 

transitions of care, and although servicemembers may misuse or 

discontinue their use of medications at any time, including while they are 

under a provider’s care, literature suggests there is greater risk for these 

issues during transition periods.7

 

7

See for example, E. A. Coleman, et al., “The Care Transitions Intervention: results of a 

randomized controlled trial,” Archives of Internal Medicine, vol. 166, no. 17 (2006).

Background 
Page 6 GAO-13-26 DOD and VA Health Care

DOD provides health care to active duty servicemembers; Reservists and 

National Guard members on active duty;8 and other beneficiaries, such as 

family members and retired servicemembers. Through TRICARE and a 

direct-care system of military treatment facilities operated by the 

Departments of the Army, Navy, and Air Force, DOD offers 

comprehensive health care coverage, including outpatient and inpatient 

care, preventive care, prescription medication coverage, and mental 

health care.9

TRICARE beneficiaries may obtain prescription medications through 

military treatment facility pharmacies, network and nonnetwork retail 

pharmacies, and the TRICARE mail-order pharmacy. DOD is required by 

law to make all clinically appropriate medications available to 

servicemembers, and, with the exception of several classes of 

medications, such as smoking-cessation and weight-loss medications, 

DOD makes all Food and Drug Administration-approved medications 

available.

Beneficiaries also can obtain care from civilian health care 

providers.

10 DOD’s formulary includes a list of medications that all military 

treatment facilities must provide and a list of medications that military 

treatment facilities may elect to provide on the basis of the types of 

services offered at that facility (e.g., cancer medications).11

When discharging or demobilizing, some servicemembers are eligible for 

transitional health care benefits through TRICARE. For example, the 

Transitional Assistance Management Program provides 180 days of 

DOD also can 

classify medications “nonformulary” on the basis of its evaluation of their 

cost and clinical effectiveness. Nonformulary medications are available to 

beneficiaries at a higher cost, unless the provider can establish medical 

necessity.

 

8

Reservists and National Guard members on active duty for more than 30 days are 

covered by TRICARE. They also may be eligible for TRICARE coverage prior to active 

duty and after active duty and may be eligible to purchase TRICARE coverage when they 

return to inactive status. See GAO, Defense Health Care: DOD Lacks Assurance That 

Selected Reserve Members Are Informed about TRICARE Reserve Select, GAO-11-551

(Washington, D.C.: June 3, 2011).

9

According to DOD, as of September 2012, there were 244 military treatment facilities.

10See 10 U.S.C. § 1074g(a)(3); 32 C.F.R. §§ 199.4(g), 199.21(h)(3)(iii).

11A formulary is a list of medications, grouped by medication class, that a health care 

system’s providers are expected to use when prescribing medications.

DOD Health Care
Page 7 GAO-13-26 DOD and VA Health Care

benefits to certain eligible servicemembers, including Reservists and 

National Guard members.12 These servicemembers could therefore be 

eligible for both DOD and VA health care during this period.13

Veterans who served in active military duty and who were discharged or 

released under conditions other than dishonorable are generally eligible 

for VA health care.14 Reservists and National Guard members also may 

be eligible for VA health care if they were called to active duty by a 

federal order and completed the full period for which they were called. 

Reservists and National Guard members also can be eligible for VA 

health care when they demobilize from combat operations, even if they 

have not separated from military service. In general, veterans must enroll 

in VA health care to receive VA’s medical benefits package—a set of 

services that includes a full range of hospital and outpatient services, 

prescription medications, and noninstitutional long-term care services.15

VA provides health care services at various types of facilities, including 

VA medical centers.16

Veterans may obtain prescription medications through VA’s mail-order 

pharmacy and medical center pharmacies. VA has a national formulary 

that provides access to medications for eligible beneficiaries. VA makes 

 

12Reservists and National Guard members can transition from DOD health care both 

when they discharge from the military, under circumstances such as retirement, and when 

they separate from active duty. 

13Similarly, retired servicemembers also could be eligible for both TRICARE and VA 

benefits. 

14Any veteran who has served in a combat theater after November 11, 1998, including 

OEF/OIF/OND veterans, and who was discharged or released from active military duty on 

or after January 28, 2003, has up to 5 years from the date of the veteran’s most recent 

discharge or release from active duty service to enroll in VA’s health care system and 

receive VA health care services. See 38 U.S.C. § 1710(e)(1)(D),(e)(3). For those veterans 

who do not enroll during their enhanced eligibility period, eligibility for enrollment and 

subsequent care is based on other factors such as compensable service-connected 

disability, VA pension status, catastrophic disability determination, or financial 

circumstances. 

15VA’s enrollment system includes eight categories for enrollment, with priority generally 

based on service-connected disability, low income, and other recognized statuses such as 

former prisoners of war. See 38 U.S.C. § 1705; 38 C.F.R. § 17.36.

16According to VA, as of June 2012, there were 152 medical centers.

VA Health Care
Page 8 GAO-13-26 DOD and VA Health Care

decisions about whether to add medications to its formulary on the basis 

of clinical and cost effectiveness and, like DOD, provides access to 

nonformulary medications when a physician attests that there is a 

compelling clinical reason to do so through its nonformulary request 

process.17 Veterans also may receive health care funded by sources 

other than VA, including private insurance, Medicare, and Medicaid.

The process and length of time for transitioning servicemembers’ health 

care from DOD to VA or another health care system varies. For instance, 

some servicemembers separate from the military and have their first 

appointment at VA the following week. Others may take more time to 

transition to VA, waiting months or years before scheduling their first 

appointment. Furthermore, some servicemembers may not transition their 

care to VA at all and instead seek care from other health care providers.

As GAO has previously reported, DOD and VA have created a number of 

clinical and nonclinical programs to assist servicemembers during 

transitions between the two departments.18 For example, to improve case 

management during transitions,19 there are programs such as Army 

Warrior Transition Units (WTU)20

 

17Each VA medical center is responsible for establishing a process to adjudicate 

nonformulary medication requests that ensures decisions are evidence-based in 

accordance with certain prescribing criteria. Medical centers are required to adjudicate 

nonformularly medication requests within 96 hours.

and the VA OEF/OIF/OND Care 

18GAO, DOD and VA Health Care: Federal Recovery Coordination Program Continues to 

Expand but Faces Significant Challenges, GAO-11-250 (Washington, D.C.: Mar. 23, 

2011); VA and DOD Health Care: Progress Made on Implementation of 2003 President’s 

Task Force Recommendations on Collaboration and Coordination, but More Remains to 

Be Done, GAO-08-495R (Washington, D.C.: Apr. 30, 2008); DOD and VA: Preliminary 

Observations on Efforts to Improve Health Care and Disability Evaluations for Returning 

Servicemembers, GAO-07-1256T (Washington, D.C.: Sept. 26, 2007); DOD and VA 

Outpatient Pharmacy Data: Computable Data Are Exchanged for Some Shared Patients, 

but Additional Steps Could Facilitate Exchanging These Data for All Shared Patients,

GAO-07-554R (Washington, D.C.: Apr. 30, 2007).

19According to the Case Management Society of America, case management is a 

collaborative process of assessment, planning, facilitation, and advocacy for options and 

services to meet an individual’s health needs through communication and available 

resources to promote quality cost-effective outcomes.

20WTUs provide a comprehensive program of medical care, rehabilitation, professional 

development, and personal goals for wounded, ill, and injured servicemembers to help 

them remain in the Army or transition to civilian life.

Transitions of Care
Page 9 GAO-13-26 DOD and VA Health Care

Management Program.21 DOD and VA also have longstanding efforts to 

improve the two departments’ health information exchange capabilities. 

For exchanging health information, the departments have relied on a 

patchwork of initiatives involving existing DOD and VA systems to 

increase electronic health record interoperability, including an initiative to 

share electronic health information, such as outpatient pharmacy data, on 

separated servicemembers. GAO has reported on challenges DOD and 

VA have faced in their data-sharing efforts—for example, challenges in 

planning, staffing, and budgeting—and that the departments are still 

working to overcome many of these issues.22

Medication management is a key component of successful transitions of 

care.23 According to the National Transitions of Care Coalition—a 

nonprofit organization that produces tools and resources to assist with 

transitions of care—transitions should include education and counseling 

about medication adherence, medication lists at discharge, and a plan for 

how to get medications during transitions.

Ensuring that patients take medications as prescribed is a challenge that 

is well-documented in literature. Research shows that patients may not 

adhere to their prescribed medication regimens—for example by misusing 

or inappropriately discontinuing medications.24

 

21The OEF/OIF/OND Care Management Program is located at every VA medical center 

and provides case management services to any OEF/OIF/OND veteran who is identified 

as high risk or who requests case management.

22See, for example, GAO, Electronic Health Records: DOD and VA Should Remove 

Barriers and Improve Efforts to Meet Their Common System Needs, GAO-11-265

(Washington, D.C.: Feb. 2, 2011); Electronic Health Records: DOD and VA Interoperability 

Efforts Are Ongoing; Program Office Needs to Implement Recommended Improvements, 

GAO-10-332 (Washington, D.C.: Jan. 28, 2010); and Electronic Health Records: DOD 

and VA Have Increased Their Sharing of Health Information, but More Work Remains, 

GAO-08-954 (Washington, D.C.: July 28, 2008).

23Other key components of successful transitions of care include identifying a clinician to 

coordinate patients’ transitions, coaching and education to support self-management, and 

information sharing between providers (including a discharge summary). See National 

Transitions of Care Coalition, Care Transition Bundle: Seven Essential Intervention 

Categories and Crosswalk (Washington, D.C.: Feb. 28, 2011).

24See for example, RAND, A Review of Barriers to Medication Adherence: A Framework 

for Driving Policy Options (Santa Monica, Calif.: 2009). 

Reasons for Medication 

Challenges during 

Transitions 
Page 10 GAO-13-26 DOD and VA Health Care

Patients can misuse their medications by taking medications in ways 

other than how they were prescribed. This can include taking more than 

was prescribed, for instance if a servicemember decides to increase his 

or her dose of pain medication without the supervision of a physician. It 

may also include cutting pills in an effort to reduce the dose or make the 

prescription last longer, which can change the absorption of certain 

medications such as extended-release formulations. Both of those 

scenarios can potentially lead to adverse effects, including overdose and 

death.

Patients may inappropriately discontinue their use of medications—

including psychiatric and pain medications—for a variety of reasons, 

according to literature.25

Although patients may misuse or inappropriately discontinue their use of 

medications at any time, including while they are under a provider’s care, 

literature suggests there is greater risk for these issues during transition 

periods. For example, some servicemembers may make their health care 

a lower priority when they return to their civilian responsibilities. Others 

may experience delays setting up appointments with health care 

providers and, as a result, discontinue use of medications.

In particular, patients may stop taking their 

medications because they do not think the medication is working; some 

providers indicated this might be more likely to happen with 

servicemembers who are on pain medications such as nonsteroidal antiinflammatory medications. Symptoms associated with a mental health 

condition, such as paranoia associated with PTSD, which is prevalent 

among returning servicemembers, also may make a discontinuation more 

likely.

 

25See, for example, World Health Organization, Adherence to Long-Term Therapies: 

Evidence for Action (Geneva, Switzerland: 2003).
Page 11 GAO-13-26 DOD and VA Health Care

About 1 in 12 (approximately 94,000) servicemembers discharged and 

Reservists and National Guard members demobilized from fiscal years 

2009 through 2011 had a psychiatric or pain medication, and almost half 

of these servicemembers subsequently received care from VA within 

9 months. Both the percentage and total number of servicemembers 

discharged and demobilized with psychiatric or pain medications 

increased slightly across the 3 fiscal years. Servicemembers who were 

discharged from military service were more likely to have psychiatric or 

pain medications than Reservists and National Guard members who 

demobilized. (See table 1.)

Table 1: Servicemembers Discharged and Reservists and National Guard Members Demobilized with Psychiatric or Pain 

Medications, Fiscal Years 2009 through 2011

Fiscal year Total

With psychiatric 

medications

With pain 

medications

With both 

psychiatric and 

pain medications

Total with 

psychiatric or 

pain medications

2009 407,078 12,352 (3.0%) 13,681 (3.4%) 3,914 (1.0%) 29,947 (7.4%)

2010 407,305 13,061 (3.2%) 13,509 (3.3%) 4,169 (1.0%) 30,739 (7.5%)

2011 378,277 15,105 (4.0%) 14,836 (3.9%) 5,127 (1.4%) 35,068 (9.3%)

Total (2009-2011)a 1,128,845 40,009 (3.5%) 41,417 (3.7%) 13,033 (1.2%) 94,459 (8.4%)

Servicemembers who 

discharged from military service 888,113b 36,896 (4.2%) 34,884 (3.9%) 11,939 (1.3%) 83,719 (9.4%)

Reservists and National Guard 

members who demobilized 240,732 3,113 (1.3%) 6,533 (2.7%) 1,094 (0.5%) 10,740 (4.5%)

Source: GAO analysis of DOD data.

Notes: Servicemembers discharged refer to active duty servicemembers, Reservists, and National 

Guard members who discharged from military service generally under conditions other than 

dishonorable.

Each of the medication categories—psychiatric medications, pain medications, and both psychiatric 

and pain medications—is mutually exclusive. For example, a servicemember with psychiatric 

medications but not pain medications is counted only in the “with psychiatric medications” column. A 

servicemember with both psychiatric and pain medications is counted only in the “with both 

psychiatric and pain medications” column.

Data on psychiatric and pain medications refer to prescriptions for psychiatric and pain medications 

that were filled, not all prescriptions that were written.

a

The number of servicemembers in each fiscal year does not sum to the total number of 

servicemembers across all 3 fiscal years because servicemembers discharged from the military or 

demobilized in more than 1 fiscal year are counted only once in the total.

b

The total number of servicemembers who discharged from military service includes 486,467 active 

duty servicemembers, 371,995 Reservists and National Guard members, and 29,651 

servicemembers who discharged from military service as both an active duty servicemember and a 

Reservist or National Guard member during the 3 fiscal years.

About 1 in 12 

Transitioning 

Servicemembers Had 

Psychiatric or Pain 

Medications; Almost 

Half Subsequently 

Received VA Care
Page 12 GAO-13-26 DOD and VA Health Care

The most common psychiatric medications for servicemembers 

discharged and Reservists and National Guard members demobilized 

from fiscal years 2009 through 2011 included sertraline (used to treat 

depression, PTSD, and anxiety disorders), while the most common pain 

medications included prescription-strength ibuprofen (used to treat mild to 

moderate pain) and oxycodone acetaminophen (used to treat moderate to 

severe pain). (See table 2.)

Table 2: Most Common Psychiatric and Pain Medications for Servicemembers Discharged and Reservists and National Guard 

Members Demobilized, Fiscal Years 2009 through 2011

Generic name (medication class)

Percentage of total psychiatric 

or pain medications at 

discharge or demobilization

Examples of conditions or symptoms for 

which medication is commonly prescribed

Psychiatric medications

1. Sertraline (antidepressant) 12.4 Depression, PTSD, and anxiety disorders

2. Citalopram (antidepressant) 10.5 Depression

3. Trazodone (antidepressant) 7.5 Depression

4. Buproprion (antidepressant) 6.8 Depression

5. Quetiapine (atypical antipsychotic) 6.0 Depression 

Pain medications

1. Ibuprofen (nonsteroidal anti-inflammatory) 19.0 Mild to moderate pain 

2. Naproxen (nonsteroidal anti-inflammatory) 12.9 Mild to moderate pain

3. Meloxicam (nonsteroidal anti-inflammatory) 12.7 Mild to moderate pain

4. Celecoxib (nonsteroidal anti-inflammatory) 7.4 Mild to moderate pain

5. Oxycodone acetaminophen (opioid) 7.1 Moderate to severe pain

Source: GAO analysis of DOD data.

Notes: Servicemembers discharged refer to active duty servicemembers, Reservists, and National 

Guard members who discharged from military service generally under conditions other than 

dishonorable.

Data on psychiatric and pain medications refer to prescriptions for psychiatric and pain medications 

that were filled, not all prescriptions that were written.

Officials stated that appropriate medication management varies across 

pain and psychiatric medications. For example, they noted that 

discontinuation of a nonsteroidal anti-inflammatory pain medication, such 

as ibuprofen, can typically be done by the servicemember without the 

supervision of a provider; patients do not typically become physically 

dependent on these medications and therefore these medications do not 

cause withdrawal symptoms when they are discontinued. In contrast, 

officials told us that people taking pain medications such as oxycodone 

acetaminophen, an opioid, for several weeks and people taking any of the 

psychiatric medications, including quetiapine, an antipsychotic, should 
Page 13 GAO-13-26 DOD and VA Health Care

only discontinue use of the medications under the supervision of a health 

care provider because of potential side effects.

Although not all servicemembers who are discharged from military service 

or demobilized receive care from VA, we found that almost half of 

servicemembers with psychiatric or pain medications in fiscal years 2009 

through 2011 subsequently received care from VA within 9 months. (See 

table 3.) Among these servicemembers, the average number of days 

between a servicemember’s date of discharge or demobilization and first 

VA appointment was 81 days (about 3 months). Across the 3 fiscal years 

of data we reviewed, we found that about one-third of servicemembers 

received care at VA within 1 month.

Table 3: Servicemembers Discharged and Reservists and National Guard Members Demobilized with Psychiatric or Pain 

Medications from Fiscal Years 2009 through 2011 Who Subsequently Received Care from VA 

Fiscal year

Total with 

psychiatric or 

pain medications

With psychiatric 

medications who 

subsequently 

received care 

from VA

With pain 

medications who 

subsequently 

received care 

from VA

With both 

psychiatric and 

pain medications 

who subsequently 

received care 

from VA

Total with 

psychiatric or 

pain medications 

who subsequently 

received care

from VA

2009 29,947 5,754 5,418 2,475 13,647 (45.6%)

2010 30,739 6,556 5,391 2,668 14,615 (47.5%)

2011 35,068 7,670 5,680 3,263 16,613 (47.4%)

Total (2009-2011)a 94,459 19,720 16,200 8,311 44,231 (46.8%)

Source: GAO analysis of DOD and VA data.

Notes: Servicemembers discharged refer to active duty servicemembers, Reservists, and National 

Guard members who discharged from military service generally under conditions other than 

dishonorable.

Data on psychiatric and pain medications refer to prescriptions for psychiatric and pain medications 

that were filled, not all prescriptions that were written.

We limited our analysis to servicemembers who received care from VA within 9 months of discharge 

or demobilization to provide consistent data across each of the 3 fiscal years—the most current 

available data at the time of our review was from June 2012, 9 months after the end of fiscal year 

2011.

a

The number of servicemembers in each fiscal year does not sum to the total number of 

servicemembers across all 3 fiscal years because servicemembers discharged from the military or 

demobilized in more than 1 fiscal year are counted only once in the total.
Page 14 GAO-13-26 DOD and VA Health Care

Efforts DOD and VA have in place that are directed to all servicemembers 

are limited in their ability to help servicemembers manage their 

medication needs during transitions of care. However, certain groups are 

eligible for additional assistance transitioning their health care, including 

medication management. Additionally, some DOD military treatment 

facilities and VA medical centers have efforts that can help manage 

servicemembers’ medication needs, but the efforts may not be available 

at all facilities.

DOD and VA have several efforts that may help servicemembers manage 

their medications during transitions, but these efforts are limited in terms 

of their ability to ensure that all servicemembers have the necessary help 

during this period. Although DOD does not have a formal policy for 

transitioning medication needs for all servicemembers, the two 

departments have broader policies, programs, and procedures that 

provide assistance to servicemembers with aspects of their transition 

more generally. Additionally, there are components of these efforts that 

may help servicemembers manage their medications during the transition 

from DOD to VA, but none of them are focused specifically on medication 

management. These efforts can occur at several phases of the transition: 

prior to a servicemember’s discharge from the military; during the 

transition between the two departments; and once a veteran seeks care 

at a VA facility. (See fig. 1.)

DOD’s and VA’s 

Efforts May Not Help 

All Servicemembers 

Manage Their 

Medication Needs 

during Transitions of 

Care

DOD and VA Efforts 

Directed at All 

Servicemembers Are 

Limited in Their Ability to 

Help Manage Transitional 

Medication Needs
Page 15 GAO-13-26 DOD and VA Health Care

Figure 1: DOD and VA Efforts Available to All Servicemembers That May Help 

Servicemembers Manage Their Medications during Transitions of Care

Prior to discharge, DOD officials identified the medical assessment—an 

interview between the discharging servicemember and a physician, 

physician assistant, or nurse practitioner occurring prior to separation—as 

the medical effort DOD has in place to help servicemembers transition 

their medical needs as they discharge from the military.26

 

26For Reservists and National Guard members demobilizing, the post-deployment health 

assessment—the DOD process for assessing the medical condition of servicemembers 

after demobilization—may identify servicemembers who need medical assistance and 

may trigger a referral for care. Reservists and National Guard members may receive VA 

care prior to separating from the military.

The 

assessment is not designed to address medication management; rather, 

its purpose is to document servicemembers’ health at the time of 

separation and to record injuries or illnesses incurred during military 

service. The assessment does, however, include a review of current 

medications. Additionally, if the health care provider conducting the 

medical assessment believes a physical exam is appropriate, or if the 

Prior to Discharge 
Page 16 GAO-13-26 DOD and VA Health Care

servicemember requests one, the servicemember will receive one—

commonly referred to as a separation physical.27

Although the medical assessment may help servicemembers manage 

their medications during transitions, its ability to do so is limited. First, 

although the assessment includes a review of medications prior to 

discharge, the assessment may not include certain best practices for 

transitioning medication needs, such as developing a plan for how to get 

medications during the transition and providing a medication list. Second, 

the medical assessment and separation physical can occur up to 

6 months before a servicemember’s separation date, and therefore may 

not be the servicemember’s final medical appointments in the military, 

making it difficult for the provider to counsel the servicemember on 

medication management during the transition. Counseling about 

medication management is a critical component of successful transitions 

of care.

DOD and VA each have a telephone hotline—DOD’s Military OneSource 

and VA’s Veterans Crisis Line—available to help servicemembers and 

veterans with a variety of issues, including medication management. 

Specifically, Military OneSource provides resources and information to 

servicemembers and veterans on a range of topics—including health 

care, education, career training, finance, and family support—and VA’s 

Veterans Crisis Line is available for servicemembers and veterans to call 

to connect with local VA medical centers. Although Military OneSource 

and VA’s Veterans Crisis Line are available for servicemembers and 

veterans to call at any time,28

 

27The requirements for a separation physical vary among the military services. In the 

Army, retirees are required to have a separation physical, but servicemembers who are 

separating at the end of their term of service are not required to have a physical. 

Servicemembers in the Army also may waive the separation physical if they have 

undergone a physical examination within 12 months of separation.

providers told us these hotlines are 

particularly useful during transitions of care. For instance, some DOD 

providers said they tell servicemembers to call Military OneSource if they 

need assistance during their transition. Similarly, a VA nurse who 

responds to referrals from VA’s Veterans Crisis Line said that she 

frequently receives referrals from the hotline from veterans who have 

28According to DOD officials, Military OneSource received approximately 1,500 calls daily 

in May 2012. The national coordinator of VA’s Veterans Crisis Line said the hotline 

receives more than 1,000 calls daily.

During the Transition
Page 17 GAO-13-26 DOD and VA Health Care

problems with their medications, such as when they have let their 

medications lapse after discharging from the military and their symptoms 

have reemerged or they have experienced withdrawal symptoms. The 

national coordinator of VA’s Veterans Crisis Line told us hotline 

responders estimate that they receive about one call per day from a 

transitioning veteran with a medication issue.

For servicemembers who transition to VA, there are departmental policies 

that can assist with medication needs upon entry into VA’s health care 

system, including VA’s nonformulary policy, DOD and VA’s data-sharing 

initiative, and VA’s policies for providing urgent care. Specifically, VA’s 

nonformulary policy—allowing providers to prescribe medications not on 

VA’s formulary if they establish clinical necessity—can help newly 

transitioned veterans avoid medication discontinuations due to 

differences in DOD’s and VA’s formularies. VA providers said they will 

typically continue existing medication therapies for patients who are new 

to VA, even if the medication is not on VA’s formulary, as long as the 

medication is effective and the veteran is stable on the medication. VA 

providers said their nonformulary requests are rarely denied and they 

have been able to keep new patients on nonformulary medications, or 

switch them to formulary medications when appropriate. A draft VA policy 

documents that VA providers are permitted to change previously 

prescribed DOD medications to medications on VA’s formulary for 

servicemembers who have separated from military service.29

 

29The draft policy also states that VA providers should continue DOD medication regimens 

for active duty servicemembers who are receiving care at VA. It clarifies that once a 

servicemember separates from the military, VA providers are permitted to change 

medications as appropriate. VA officials told us that they anticipate the policy will be 

released in December 2012.

Some VA 

providers said they may change a new VA patient’s nonformulary 

medication to a VA formulary medication, but usually not when the patient 

is first entering VA, noting that it is important to establish relationships 

with patients before changing their medications. When comparing DOD’s 

and VA’s formularies for psychiatric and pain medications, we found that 

more than 50 percent of the psychiatric and pain medications on DOD’s 

formulary as of March 12, 2012, were also on VA’s formulary, and these 

medications represented the most utilized psychiatric and pain 

medications on DOD’s formulary in fiscal year 2011. Specifically, the 

medications on DOD’s formulary that were also on VA’s formulary 

represented 90 and 96 percent of the total number of prescriptions for 

Entry to VA
Page 18 GAO-13-26 DOD and VA Health Care

psychiatric and pain medications, respectively. (See app. II for our 

comparison of DOD’s and VA’s formularies for psychiatric and pain 

medications.)

Additionally, to help servicemembers transition to VA, DOD and VA have 

a data-sharing initiative that allows DOD to electronically share historical 

health information, including outpatient pharmacy data, on separated 

servicemembers with VA on a monthly basis. Through this initiative, 

known as the Federal Health Information Exchange, DOD transmits 

certain information into a shared repository that VA can access and pull 

into its own record system, available at all VA facilities.30

VA also has national policies in place to prioritize patients with urgent 

health care needs and to provide such care on an expedited basis. 

Following these policies, each VA medical center we visited had 

procedures to accommodate “walk-in” patients—those who do not have 

an appointment—who had not previously received care at VA and had an 

urgent medical need. VA providers told us they ensure such patients are 

seen the same day they walk in to the facility and, in the case of an 

urgent medication need, are given enough medication to cover the period 

The purpose of 

the data-sharing initiative is to improve the safety and quality of care 

provided at VA and to reduce costs by avoiding duplicative services. 

Moreover, sharing of pharmacy data is important for medication 

management during transitions because it improves continuity of care. 

Although some VA providers access and use shared pharmacy data, 

others told us they were not aware that they could access DOD data 

through VA’s system, or could not always find DOD data, and as a result 

had determined that looking for it typically was not worthwhile. DOD and 

VA officials said that the data-sharing initiative is fully operational and 

accessible at every VA facility. They said providers who do not use it may 

not be familiar with how to access data or aware of what information is 

available. They added that the information may not be as useful to 

providers if veterans sought care from a private provider before coming to 

VA because in those cases DOD’s data are not the veterans’ most recent 

health information.

 

30DOD and VA also share electronic health information through the Bidirectional Health 

Information Exchange, which allows providers at both departments access to view 

information on shared patients who receive care from both DOD and VA. This initiative 

may help transition health care needs for Reservists and National Guard members who 

may receive VA care prior to separating from the military. 
Page 19 GAO-13-26 DOD and VA Health Care

until they can come in for a full assessment. Providers told us they 

generally are able to provide any type of medication on a short-term 

basis, including nonformulary medications and less commonly prescribed 

medications, as long as patients are able to document their use of a 

particular medication. VA providers told us that such walk-ins are 

common and that walk-in procedures are in place so that any veteran 

who is eligible for care will not be left with an unmet need. The National 

Transitions of Care Coalition states that providing timely access to 

healthcare providers is a critical component of safe and effective 

transitions of care.

In addition to the efforts available to all servicemembers, DOD and VA 

have developed efforts for specific servicemember groups—such as 

servicemembers with more complex health care needs or with mental 

health conditions—that are designed to provide more thorough and direct 

assistance with transitioning their health care, including components to 

help address medication needs. (See fig. 2.)

DOD and VA Provide 

Additional Assistance to 

Meet Transitional 

Medication Needs for 

Specific Servicemember 

Groups 
Page 20 GAO-13-26 DOD and VA Health Care

Figure 2: DOD and VA Efforts Targeted to Specific Servicemember Groups That 

Provide Additional Assistance to Help Manage Medication Needs during Transitions 

of Care 
Page 21 GAO-13-26 DOD and VA Health Care

Prior to discharge, DOD and VA have several additional efforts available 

to servicemembers with complex health care needs or mental health 

conditions that provide assistance with transitioning their medication 

needs—including case management services and access to staff whose 

primary focus is helping servicemembers connect with VA health care 

services. 

For example, servicemembers with complex health care needs may 

receive case management services through military case managers or 

Army WTUs, to help coordinate their medical care as they transition out of 

the military, including medication management.31 Military case 

management services are available to servicemembers who have 

catastrophic or multiple medical needs, which could include managing 

medications. Family issues, seeing multiple providers, and a history of 

noncompliance are also indicators of a need for military case 

management. Military case managers are required to help connect 

separating servicemembers with new health care providers and to assist 

them with transitioning their health care needs, including medications. For 

example, military case managers are required to fill out the VA referral 

form and submit it, along with a discharge plan and medical record, to the 

VA representative at the military treatment facility or the receiving VA 

medical center.32

Additionally, transitioning servicemembers in the Army with complex 

health care needs may receive assistance through Army WTUs. The 

Army WTU program is available to wounded Army servicemembers 

whose injuries preclude them from contributing to their unit’s mission or 

whose injuries are severe enough to require case management in order 

to properly rehabilitate. According to Army officials, WTUs served nearly 

19,000 servicemembers during fiscal year 2011. WTUs are designed to 

help servicemembers remain in the Army or transition to civilian life, 

guided by a Comprehensive Transition Plan to facilitate their process of 

recovery and transition. Servicemembers are also assisted by a “Triad of 

 

31Military case managers and WTUs provide similar services for servicemembers with 

complex health care needs, and DOD officials told us that unit commanders and military 

clinicians use judgment in determining which is most appropriate for a servicemember. 

Military case managers are also available to retirees and dependents, while WTUs are 

limited to active duty servicemembers, Reservists, and National Guard members.

32See Department of Defense, TRICARE Management Activity, Medical Management 

Guide (Washington, D.C.: 2009).

Prior to Discharge
Page 22 GAO-13-26 DOD and VA Health Care

Care” team—composed of a nurse case manager, primary care manager, 

and squad leader. WTU policy requires nurse case managers to ensure a 

“warm handoff” to the VA either by connecting the servicemember with a 

VA representative stationed at the military treatment facility, or by 

assisting the servicemember with the VA enrollment process and 

contacting the receiving VA to coordinate follow-up care.33 For example, 

the primary care and nurse case managers at facilities we visited without 

a VA representative on site told us they complete a VA referral form to 

identify any needs for specialty care, such as mental health care. As 

members of the Triad of Care team with the authority to prescribe 

medications, primary care managers—who are typically physicians—also

can help WTU servicemembers prepare to manage their medications 

during a transition. For instance, a primary care manager we spoke with 

said that she ensures servicemembers have adequate supplies of 

medications to cover their transition periods and counsels 

servicemembers about the importance of adhering to their medication 

regimens.34

Some military case managers, WTU nurse case managers, and WTU 

primary care managers we spoke with told us they take additional 

measures when helping a servicemember transition to VA, including 

giving the servicemember a hard copy of his or her medical record, 

providing a list of his or her current medications, and writing a discharge 

summary that describes the servicemember’s medical history and current 

status. In addition, some military case managers and WTU nurse case 

managers said servicemembers who have separated from the military 

sometimes contact them with questions about their health care—including 

medications. For example, servicemembers call them with questions 

about how to schedule appointments at their local VA facility because 

they need medications even though these individuals are no longer 

formally receiving military case management services. Sharing copies of 

medical records, providing a medication list, completing a discharge 

summary, and having a clearly identified practitioner to facilitate and 

 

33See Department of Defense, Department of the Army, Comprehensive Transition Plan: 

Policy and CTP-Guidance (CTP-G) (Washington, D.C.: 2011).

34Squad leaders also help servicemembers prepare to transition out of the Army by 

providing nonclinical assistance, such as ensuring that servicemembers attend required 

briefings and vocational trainings prior to their separation from the military.
Page 23 GAO-13-26 DOD and VA Health Care

coordinate a patient’s care are all best practices for transitions between 

health care providers.35

In addition to DOD military case management and Army WTUs, VA also 

provides assistance to servicemembers with complex health care needs 

prior to discharge through VA’s Liaisons for Healthcare program. The 

liaisons are VA employees stationed at military treatment facilities who 

help ensure a smooth transition for servicemembers from those facilities 

to VA.36

 

35See National Transitions of Care Coalition, Care Transition Bundle: Seven Essential 

Intervention Categories (Washington, D.C.: Feb. 28, 2011); A. M. Spehar et al., “Seamless 

Care: Safe Patient Transitions from Hospital to Home,” Advances in Patient Safety: From 

Research to Implementation (Rockville, Md.: 2005); and T. Bodenheimer, “Coordinating 

Care: A Perilous Journey through the Health Care System,” New England Journal of 

Medicine, vol. 358, no. 10 (2008):1064-1071.

For instance, at the military treatment facility we visited with VA 

liaisons, the liaisons we spoke with said they would alert receiving VA 

medical centers about potential increased risks of medication 

discontinuation for patients for whom they had concerns. VA liaisons work 

with military case managers and WTU nurse case managers at military 

treatment facilities. Specifically, military case managers and WTU nurse 

case managers at military treatment facilities with VA liaisons are able to 

work directly with these liaisons to schedule appointments and share 

medical information, eliminating the need to contact the receiving VA 

medical centers. VA liaisons told us that although servicemembers are 

typically referred to them by military or WTU case managers, they also 

can assist servicemembers at their military treatment facility who do not 

receive military or WTU case management services. According to VA, VA 

liaisons assisted with approximately 6,500 referrals to VA and provided 

28,500 educational consultations to servicemembers, families, and 

military providers in fiscal year 2011. Providers told us that 

servicemembers who receive assistance from a military case manager, 

WTU nurse case manager, or VA liaison are more likely than 

servicemembers who transition without this assistance to have a smooth 

transition from DOD to VA, including the transition of their medications.

36According to VA officials, VA’s formula for determining which military treatment facilities 

receive liaisons includes the total number of VA referrals made by each facility and patient 

acuity, among other factors. As of September 2012, there were 33 VA liaisons stationed at 

18 military treatment facilities. VA officials said that the program has been approved to 

expand to 43 liaisons at 21 military treatment facilities in fiscal year 2013.
Page 24 GAO-13-26 DOD and VA Health Care

Additionally, in March 2012, DOD released a policy to ensure continuity of 

care for servicemembers receiving mental health care that outlines how to 

appropriately transition care between providers, including addressing 

psychiatric medication needs.37

These efforts—military case management, WTUs, VA Liaisons for 

Healthcare, and DOD’s mental health continuity of care policy—all include 

elements that experts have identified as best practices for transitions of 

care, such as sharing medical information directly between providers and 

scheduling appointments with a receiving provider prior to discharge.

For instance, the policy directs the DOD 

provider to contact, as appropriate, the receiving provider to communicate 

the patient’s history, current status, needs during the transition period—

which could include medications—and to establish a follow-up 

appointment to better ensure continuity of care. It also states that the 

DOD provider should add a final summary of treatment in the patient’s 

medical record. As with other DOD policies, this policy directs the 

individual military services to develop their own detailed policies in line 

with the general guidance for transitioning servicemembers’ mental health 

care.

38

During the transition, servicemembers receiving mental health services 

are eligible for additional assistance through the inTransition program—a 

DOD program, with support from VA, established in 2010 to offer 

specialized coaching and assistance to servicemembers receiving mental 

health care as they transition between health care providers. The 

program is available to servicemembers who are transitioning within DOD 

and those who are separating from the military. Servicemembers can be 

identified for inTransition services either by self-referral or physicianreferral. Coaches for inTransition are directed to contact servicemembers 

at least once a week and are trained in motivational interviewing to 

encourage servicemembers to continue their mental health care 

treatment, which could include medications. Although many of the DOD 

and VA providers we spoke with were unfamiliar with the inTransition 

program, one DOD mental health care provider said she believes the 

inTransition program is a useful resource and she shares the inTransition 

information with her patients prior to their discharge. Similarly, a National 

 

37DOD refers to mental health care as behavioral health care. For consistency throughout 

this report and other GAO reports, we use the term mental health care.

38See National Transitions of Care Coalition, Care Transition Bundle. 

During the Transition
Page 25 GAO-13-26 DOD and VA Health Care

Guard member we interviewed during one of our site visits told us he was 

not familiar with the program but said it would be helpful if someone 

checked in on him after he demobilized and left active duty, as he 

sometimes forgets to take his medications because of the memory loss 

he experiences from an injury. According to the director of the 

inTransition program, the program provided coaching services to 

approximately 1,800 servicemembers and veterans from February 1, 

2010, through March 31, 2012. Coaching and education about how to 

self-manage one’s care during a transition are also consistent with best 

practices.39

Upon entry to VA, the OEF/OIF/OND Care Management Program can 

assist veterans with complex health care needs. Located at every VA 

medical center, the goal of the program is to coordinate patient care 

activities and ensure that OEF/OIF/OND veterans are receiving 

necessary care. Specifically, care management teams, which include 

program managers and case managers, work together to coordinate the 

care for veterans who need case management services and to receive 

patients when they arrive at VA. OEF/OIF/OND case managers also are 

required to contact veterans who have been referred by WTUs or military 

case managers prior to their first VA appointment. One veteran we 

interviewed during our site visits said he spoke with an OEF/OIF/OND 

case manager after his discharge, but prior to his first VA appointment. 

He described how he had run out of his medications—and had been 

cutting his psychiatric medication so it would last longer—and the case 

manager told him to come to a VA facility that day to see a provider and 

get his medications. Some case managers told us they also alert 

providers about any special needs, such as nonformulary medications, 

prior to a veteran’s first appointment. Prior to discharge, OEF/OIF/OND 

program managers also serve as VA contacts for all WTU nurse case 

managers, military case managers, and VA liaisons working with 

transitioning servicemembers. Although military case managers, WTU 

nurse case managers, and VA liaisons are the primary way veterans get 

connected to the OEF/OIF/OND Care Management Program, the 

program is also available to any OEF/OIF/OND veteran who arrives at a 

VA facility. Program managers are responsible for ensuring that every 

veteran of these conflicts is screened for case management services, and 

 

39See National Transitions of Care Coalition, Care Transition Bundle; T. Bodenheimer, 

“Coordinating Care”; and E. A. Coleman et al., “The Care Transitions Intervention.”

Entry to VA
Page 26 GAO-13-26 DOD and VA Health Care

veterans can request the services regardless of their screening results. 

According to VA officials, the OEF/OIF/OND Care Management Program 

was providing services to approximately 50,000 servicemembers and 

veterans at the end of fiscal year 2011.

Some DOD military treatment facilities and VA medical centers have 

developed local policies and procedures that can help servicemembers 

transition their care and manage their medications. For example, some 

military treatment facilities provide medication lists to servicemembers 

prior to discharge, and some VA medical centers conduct outreach to 

military treatment facilities. However, these efforts are not part of formal 

department-wide policies and are implemented at the discretion of 

individual facilities.

Two of the three military treatment facilities we visited had local policies 

that require providers to give patients a current medication list at the end 

of each appointment, including their last medical appointment prior to 

discharge. For instance, the list at one facility includes the medication 

name, dosage, directions for use, date of last fill, number of refills, and 

prescribing physician. Medication lists can assist servicemembers with 

medication management during transitions of care, including by helping to 

remind them to take their medications and to adhere to prescribed 

treatment regimens. Medication lists also can improve continuity of care 

during transitions by providing documentation of a patient’s current 

medications. At the military treatment facility we visited that does not have 

this type of policy, case managers and providers told us they sometimes 

provide this type of information to servicemembers even though it is not 

required at their facility. The National Transitions of Care Coalition has 

identified medication lists as a best practice during transitions to ensure 

safe use of medications and adherence to patients’ plans of care. 

Additionally, The Joint Commission, an accrediting body for health care 

organizations, includes medication lists in one of its patient safety goals.

In another example of local efforts to help meet transitional medication 

needs, officials from two VA medical centers we visited said they send 

staff to military treatment facilities or military bases without VA Liaisons 

for Healthcare to educate servicemembers about VA health care. 

According to officials at these VA medical centers, having a point of 

contact at VA increases the likelihood that servicemembers will call VA for 

care and may make them less likely to experience a discontinuation in 

their medication use. For instance, officials at one medical center we 

visited said they send OEF/OIF/OND care management staff to National 

Local DOD and VA Facility 

Efforts Can Help Meet 

Servicemembers’ 

Transitional Medication 

Needs but May Not Be 

Available at All Facilities
Page 27 GAO-13-26 DOD and VA Health Care

Guard demobilization events to help National Guard members returning 

from combat begin the process of enrolling in VA health care. Officials at 

another medical center said they send OEF/OIF/OND care management 

staff to a nearby Army military treatment facility that does not have a VA

Liaison for Healthcare so they can act as informal VA liaisons, educating 

servicemembers about VA health care and providing VA enrollment 

forms. These activities also provide servicemembers with a VA point of 

contact during their transitions. Officials at these medical centers said 

these efforts improve the transition of care between DOD and VA and can 

reduce the likelihood of a veteran discontinuing medication use. 

Additionally, two veterans we spoke with described the benefit of having 

VA staff reach out to them while they were still on active duty. 

Specifically, one veteran told us an OEF/OIF/OND case manager called 

him prior to discharging from the Army to help him schedule his first 

appointment at VA and that this connection helped ensure he had a 

smooth transition of his health care, including his medications. While 

OEF/OIF/OND Care Management program materials suggest that 

OEF/OIF/OND Care Management staff are encouraged to conduct 

outreach to active duty servicemembers, this type of outreach is not 

required by VA policy. Instead, this type of outreach is directed by local 

VA medical centers.

Continuity of health care, especially with respect to medication 

management, is important for servicemembers who are transitioning out 

of the military and changing health care providers. Ensuring psychiatric 

and pain medications are continued during transitions is particularly 

important given the potential adverse health effects that can be 

experienced in response to misusing or abruptly discontinuing them. 

Given that DOD may be the last provider of health care prior to discharge, 

the department has primary responsibility for preparing servicemembers 

for transitions of care. DOD’s medical assessment is a key opportunity for 

assisting all servicemembers with managing medications, but there is no 

assurance that best practices, such as providing current medication lists 

at the point of discharge, are included in these assessments. Additionally, 

although DOD and VA have several other efforts that implement one or 

more best practices for managing medications during transitions, these 

efforts are available only to specific groups or to servicemembers 

accessing certain DOD or VA facilities. DOD does not have a departmentwide policy to help ensure that all transitioning servicemembers’ 

medication needs are managed. Without such a policy, DOD cannot 

ensure, for example, that the basic step of providing current medication 

lists at the point of discharge is implemented across all its military 

Conclusions 
Page 28 GAO-13-26 DOD and VA Health Care

facilities, including for the approximately 50 percent of servicemembers 

discharged with psychiatric or pain medications who do not connect with 

VA providers in a timely manner, if at all. As such, the departments 

cannot be assured that servicemembers’ medication needs are 

sufficiently met during transitions. Furthermore, best practices 

implemented locally or in specialized programs—such as scheduling VA 

appointments prior to discharge for WTU servicemembers—could benefit 

a broader population of servicemembers. Identifying best practices and 

implementing them across the departments could better ensure overall 

continuity of care, including medication management, for servicemembers 

transitioning between health care providers.

To help ensure appropriate medication management for all 

servicemembers during transitions, we recommend that the Secretary of 

Defense direct the Under Secretary of Defense for Personnel and 

Readiness to develop a formal DOD transition policy for medications that 

applies to all servicemembers, including a requirement that all 

servicemembers be provided a current medication list prior to 

transitioning out of the military and changing health care providers.

We also recommend that the Secretary of Defense direct the Under 

Secretary of Defense for Personnel and Readiness, and the Secretary of 

Veterans Affairs direct the Under Secretary for Health, to work together to 

identify and apply best practices for managing servicemembers’ 

medication needs during transitions of care, including assessing the 

extent to which practices currently available within existing transition 

policies and programs that are targeted to specific servicemember and 

veteran groups can be made more widely available.

We provided a draft of this report to DOD and VA for comment. Both 

departments concurred with our recommendations, and the departments’ 

responses are reprinted in appendixes III and IV. In its response, DOD 

provided comments on the medication list component of our 

recommendation for it to develop a transition policy for medications that 

applies to all servicemembers. DOD stated that servicemembers may 

receive a copy of their medical records, which would include a list of 

current medications. However, DOD does not provide all servicemembers 

a copy of their medical records. DOD also indicated that medication 

Recommendations for 

Executive Action

Agency Comments 

and Our Evaluation
Page 29 GAO-13-26 DOD and VA Health Care

information for servicemembers is already shared with VA through the 

Bidirectional Health Information Exchange. However, as we noted in our 

report, this data-sharing initiative is limited to shared patients—such as 

servicemembers who receive care from both DOD and VA prior to 

separating from the military. Moreover, not all servicemembers 

discharged from DOD subsequently receive care from VA. We believe 

that it is important that all servicemembers transitioning out of the DOD 

health care system be provided with a medication list at discharge, which 

is important for helping to ensure medications are used appropriately and 

that there is continuity of care for servicemembers changing health care 

providers.

In response to our recommendation that DOD and VA work together to 

identify and apply best practices for managing servicemembers’ 

medication needs during transitions of care, DOD specified that it would 

work with VA to identify best practices such as reducing medication 

errors. As DOD identifies and applies best practices, it should focus on 

practices that will help manage servicemembers’ medication needs during 

transitions of care. As we have identified in our report, some of these best 

practices are currently available within existing transition policies and 

programs and could be made more widely available. Additionally, VA 

stated that its Veterans Health Administration has several efforts under 

way to address the challenges associated with the medication needs of 

transitioning servicemembers. VA also provided technical comments, 

which we have incorporated as appropriate.

As agreed with your office, unless you publicly announce the contents of 

this report earlier, we plan no further distribution until 12 days from the 

report date. At that time, we will send copies of this report to the 

Secretary of Defense, Secretary of Veterans Affairs, and appropriate 

congressional committees. In addition, the report will be available at no 

charge on the GAO website at http://www.gao.gov. 
Page 30 GAO-13-26 DOD and VA Health Care

If you or your staff have any questions about this report, please contact 

me at (202) 512-7114 or draperd@gao.gov. Contact points for our Offices 

of Congressional Relations and Public Affairs may be found on the last 

page of this report. GAO staff who made key contributions to this report 

are listed in appendix V. 

Sincerely yours,

Debra A. Draper

Director, Health Care
Appendix I: Scope and Methodology

Page 31 GAO-13-26 DOD and VA Health Care

To determine the extent to which servicemembers transitioned out of the 

Department of Defense (DOD) health care system with psychiatric or pain 

medications, we obtained data from DOD’s Defense Manpower Data 

Center and Defense Health Cost Assessment and Program Evaluation on 

the number of servicemembers who discharged and Reservists and 

National Guard members who demobilized with psychiatric or pain 

medications in fiscal years 2009, 2010, and 2011. The Defense 

Manpower Data Center provided us with a list of active duty 

servicemembers, Reservists, and National Guard members who 

discharged or were released (including retirees) from military service 

generally under conditions other than dishonorable and a list of 

Reservists and National Guard members who demobilized. We included 

servicemembers who discharged and Reservists and National Guard 

members who demobilized because servicemembers in both of these 

populations can transition out of the DOD health care system and could 

be eligible for VA care. For servicemembers who had multiple discharge 

or demobilization dates within a fiscal year, we used the latest date. 

DOD’s Pharmacoeconomic Center provided us with a list of psychiatric 

and pain medications.1

To determine how many of those servicemembers discharged from 

military service and Reservists and National Guard members demobilized 

with psychiatric or pain medications subsequently received care at the 

Department of Veterans Affairs (VA), we obtained data from VA’s 

National Data System on how many of these servicemembers 

subsequently received health care from VA. We provided VA with the list 

of servicemembers who discharged from military service or demobilized 

DOD’s Defense Health Cost Assessment and 

Program Evaluation then reviewed TRICARE claims files for discharged 

and demobilized servicemembers to determine if they had a current 

psychiatric or pain medication when they discharged or demobilized. Data 

from the claims files identifies prescriptions that were filled, not all 

prescriptions that were written. Furthermore, because some psychiatric 

and pain medications may be prescribed for conditions other than mental 

health or pain conditions, the number of servicemembers with psychiatric 

or pain medications is not equivalent to the number of servicemembers 

with related conditions.

 

1

DOD’s Pharmacoeconomic Center excluded psychiatric and pain medications that were 

available over-the-counter, were bulk medications used by pharmacists for compounding, 

and were provided through certain routes of administration, such as intravenous pain 

medications. 

Appendix I: Scope and Methodology
Appendix I: Scope and Methodology

Page 32 GAO-13-26 DOD and VA Health Care

with a psychiatric or pain medication in fiscal years 2009, 2010, or 2011. 

VA compared the data to its electronic medical records to identify which 

servicemembers received care at VA within 9 months of their discharge or 

demobilization date. We selected the 9-month time frame to provide 

consistent data across each of the 3 fiscal years—the most current 

available VA data at the time of our review were from June 2012, 

9 months after the end of fiscal year 2011. Data on servicemembers who 

subsequently received care from VA do not describe the full population of 

servicemembers who received care after being discharged from military 

service or demobilized. Not all servicemembers subsequently seek and 

receive care from VA; some receive care from other sources, such as 

private providers.

We assessed the reliability of the data in several ways, including 

discussing with DOD and VA officials their methodology and datacollection techniques and conducting our own review of their 

programming and methodological approaches using data file 

documentation, code book and file dictionaries, and programming logs.

To identify the efforts DOD and VA have in place to help ensure that 

servicemembers’ psychiatric and pain medication needs are met during 

transitions of care, we reviewed documents and interviewed officials from 

DOD, the Department of the Army, and VA. We focused our review on the 

Army, rather than the other military services, because it had the largest 

number of Operation Enduring Freedom (OEF) and Operation Iraqi 

Freedom (OIF)2 servicemembers. We reviewed documents including 

DOD, Army, and VA policies related to health care and medication 

transitions. For example, we reviewed the Army Surgeon General Pain 

Management Task Force Report, VA’s National Pain Management 

Strategy, and VA/DOD Clinical Practice Guideline for Management of 

Opioid Therapy for Chronic Pain.3

 

2

Military operations in Iraq as of September 1, 2010, are referred to as Operation New 

Dawn (OND). 

We interviewed officials from DOD, 

Army, and VA headquarters offices that have oversight of, and set 

3

See Office of the Army Surgeon General, Pain Management Task Force, Providing a 

Standardized DOD and VHA Vision and Approach to Pain Management to Optimize the 

Care for Warriors and their Families (May 2010); Department of Veterans Affairs, Pain 

Management, VHA Directive 2009-053 (Washington, D.C.: Oct. 28, 2009); and 

Department of Veterans Affairs and Department of Defense, VA/DOD Clinical Practice 

Guideline for Management of Opioid Therapy for Chronic Pain (May 2010).
Appendix I: Scope and Methodology

Page 33 GAO-13-26 DOD and VA Health Care

policies related to, the provision of health care, including mental health 

and pain care and prescription-medication benefits, and that have roles in 

assisting servicemembers with their health care as they transition out of 

DOD. Specifically, we interviewed officials from

• DOD’s TRICARE Management Activity’s Clinical Quality Office, 

Pharmacoeconomic Center, and Case Management Program; 

Reserve Medical Programs; Defense Health Information Management 

System; and inTransition Program;

• Office of the Surgeon General of the Army; Army National Guard; and 

Army Pain Management Program; and

• VA’s VA/DOD Collaboration Office and Veterans Health 

Administration’s Pharmacy Benefits Management Services, Veterans 

Crisis Line, inTransition Program, Office of Health Information, Pain 

Management Program, Liaisons for Healthcare Program, and 

OEF/OIF/OND Care Management Program.

We also interviewed officials, including providers and case managers, 

from Army military treatment facilities and VA medical centers, as well as 

servicemembers and veterans, through six site visits to obtain their 

perspectives about how the departments’ efforts to transition 

servicemembers with medication needs are being implemented and to 

identify local efforts to assist servicemembers with medication 

management during transitions. We selected sites to obtain a diverse 

sample based on facility size, patient complexity, presence or absence of 

a VA Liaison for Healthcare, and Army and VA region, and to ensure 

military treatment facility proximity to a VA medical center. On the basis of 

these criteria we selected the following facilities: (1) Walter Reed National 

Military Medical Center (Bethesda, Md.); (2) Washington D.C. VA Medical 

Center; (3) Bayne-Jones Army Community Hospital (Fort Polk, La.); 

(4) Alexandria VA Medical Center (Pineville, La.); (5) Weed Army 

Community Hospital (Fort Irwin, Calif.); and (6) Loma Linda (Calif.) VA 

Medical Center. Finally, we also interviewed officials from selected 

veterans service organizations—the American Legion, Military Officers 

Association of America, and Wounded Warrior Project—to get their 

perspectives on transition policies and programs and where there are 

opportunities to improve the handoff from DOD to VA.
Appendix I: Scope and Methodology

Page 34 GAO-13-26 DOD and VA Health Care

We focused our review on efforts that department officials and local 

military treatment facility and VA medical center officials identified as 

having a role in helping servicemembers manage their medications as 

they transition from DOD to VA. We also focused on the transition efforts 

used for servicemembers transitioning between outpatient settings, rather 

than inpatient settings, because medication management between 

outpatient settings is a vulnerable point in terms of providing seamless 

care. We may not report an exhaustive list of all efforts because some 

servicemembers may have received help through efforts that were not 

identified by the officials we interviewed or through efforts that may not 

have been related to the health care aspects of their transition. We did 

not review the effectiveness of the efforts identified.

Additionally, we reviewed relevant literature on transitions of care and 

medication adherence, including effective approaches for transitioning 

health care needs and strategies for promoting patient adherence to 

medication treatment plans. For example, we reviewed literature from the 

National Transitions of Care Coalition, a nonprofit organization that works 

to address gaps that affect safety and quality of care for transitioning 

patients, to identify best practices within DOD’s and VA’s transition 

efforts.

We conducted this performance audit from January 2012 to October 2012 

in accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.
Appendix II: Formulary Comparison

Page 35 GAO-13-26 DOD and VA Health Care

In comparing DOD’s and VA’s formularies for psychiatric and pain 

medications, we determined which psychiatric and pain medications on 

DOD’s formulary were also on VA’s formulary.1 DOD’s 

Pharmacoeconomic Center provided us with a list of the psychiatric and 

pain medications on DOD’s formulary, as of March 12, 2012.2 We 

compared this list with VA’s full formulary, found on VA’s Veterans Health 

Administration’s Pharmacy Benefits Management Services website, as 

recommended by VA pharmacy officials.3 We compared medications 

using generic names; we did not compare medications based on 

differences in strength or dosage form, such as whether the medication is 

a liquid or a tablet.4

We found that 57 percent of the psychiatric and pain medications on 

DOD’s formulary were also on VA’s formulary, and these medications 

represented the most utilized psychiatric and pain medications on DOD’s 

formulary. (See table 4.) Specifically, the medications on DOD’s formulary 

that were also on VA’s formulary—62 psychiatric medications and 31 pain 

medications—represented 90 and 96 percent of the total number of 

DOD also provided data on the number of 

prescriptions filled for psychiatric and pain medications by active duty 

servicemembers to provide additional context for our comparison. We 

spoke with knowledgeable DOD pharmacy officials about the data, 

including their methodology for identifying psychiatric and pain 

medications, and with DOD and VA officials about our methodology for 

comparing the formularies. On the basis of these discussions, we 

determined the data to be sufficiently reliable for our purposes.

 

1

Because we focused on transitions of care from DOD to VA, we did not determine which 

medications on VA’s formulary were not on DOD’s formulary.

2

DOD’s Pharmacoeconomic Center excluded psychiatric and pain medications that were 

available over-the-counter, were bulk medications used by pharmacists for compounding, 

and were provided through certain routes of administration, such as intravenous pain 

medications.

3

VA, “VA National Formulary,” accessed March 16, 2012, 

http://www.pbm.va.gov/NationalFormulary.aspx. VA officials confirmed that there had 

been no changes to the formulary between March 12, 2012, and March 16, 2012.

4

According to DOD and VA pharmacists, differences in dosage form do not typically 

correspond to clinically significant differences. However, in some cases, different dosage 

forms may be prescribed for different clinical indications and may have significant 

implications for patients. For instance, some opioids are prescribed in an immediaterelease formulation for breakthrough pain, whereas a long-acting formulation may be 

prescribed for chronic pain.

Appendix II: Formulary Comparison
Appendix II: Formulary Comparison

Page 36 GAO-13-26 DOD and VA Health Care

prescriptions for psychiatric and pain medications, respectively, filled by 

active duty servicemembers in fiscal year 2011.

DOD and VA pharmacy officials said that some of the differences in 

DOD’s and VA’s formularies are due to differences in the structure of the 

departments’ health care systems. For example, DOD’s formulary covers 

prescriptions written by both military and civilian providers and, as a 

result, DOD officials said that the department needs to have a broader 

formulary to account for differences in prescribing practices among 

different providers. In contrast, VA has a closed system and provides 

prescriptions written by its own providers, which VA officials said allows 

VA to have more direct control over the medications that are prescribed to 

its patient population. VA officials also emphasized that VA regularly 

provides nonformulary medications to veterans through its nonformulary 

request process that allows providers to prescribe medications not on 

VA’s formulary if they can establish clinical necessity.5 VA providers at 

the three sites we visited told us that they find the nonformulary request 

process easy to use and that their nonformulary requests are rarely 

denied.

 

5

Each VA medical center is responsible for establishing a process to adjudicate 

nonformulary medication requests that ensures decisions are evidence-based in 

accordance with certain prescribing criteria. Medical centers are required to adjudicate 

nonformularly medication requests within 96 hours. 
Appendix II: Formulary Comparison

Page 37 GAO-13-26 DOD and VA Health Care

Table 4: Comparison of DOD’s and VA’s Formularies for Psychiatric and Pain 

Medications, March 2012

Medication on DOD’s formularya Medication on VA’s formulary

Percentage of DOD 

prescriptions filled 

by active duty 

servicemembers, 

fiscal year 2011

Psychiatric 

Sertraline Hydrochloride  10.7% 

Citalopram Hydrobromide  8.8

Bupropion Hydrochloride  7.5

Diazepam  7.0

Trazodone Hydrochloride  6.9

Clonazepam  5.5

Venlafaxine Hydrochloride  5.3

Fluoxetine Hydrochloride  5.2

Amphet Asp Amphet D Amphet 4.6

Quetiapine Fumarate  4.4

Amitriptyline Hydrochloride  3.5

Topiramate  3.5

Alprazolam  2.8

Lorazepam  2.5

Methylphenidate Hydrochloride  2.2

Paroxetine Hydrochloride  2.2

Mirtazapine  1.8

Duloxetine Hydrochloride 1.7

Aripiprazole  1.5

Buspirone Hydrochloride  1.4

Divalproex Sodium  1.4

Nortriptyline Hydrochloride  1.2

Lamotrigine  1.1

Risperidone  0.8

Modafinil 0.7

Olanzapine  0.5

Levetiracetam  0.5

Atomoxetine Hydrochloride 0.5

Lithium Carbonate  0.4

Oxcarbazepine 0.4

Armodafinil 0.3
Appendix II: Formulary Comparison

Page 38 GAO-13-26 DOD and VA Health Care

Medication on DOD’s formularya Medication on VA’s 

formulary

Percentage of DOD 

prescriptions filled 

by active duty 

servicemembers, 

fiscal year 2011

Dextroamphetamine Sulfate  0.3

Doxepin Hcl  0.3

Ziprasidone Hydrochloride  0.3

Carbamazepine  0.2

Desvenlafaxine Succinate 0.2

Lisdexamfetamine Dimesylate 0.1

Zonisamide 0.1

Phenytoin Sodium Extended  0.1b

Imipramine Hydrochloride  0.1

Milnacipran Hydrochloride 0.1

Fluvoxamine Maleate 0.1

Primidone  < 0.1

Desipramine Hydrochloride  < 0.1

Sodium Oxybate < 0.1

Asenapine Maleate < 0.1

Haloperidol  < 0.1

Chlorpromazine Hydrochloride  < 0.1

Chlordiazepoxide Hydrochloride  < 0.1

Lacosamide < 0.1

Clomipramine Hydrochloride  < 0.1

Phenelzine Sulfate  < 0.1

Clorazepate Dipotassium < 0.1

Nefazodone Hydrochloride < 0.1

Paliperidone  < 0.1

Dexmethylphenidate Hydrochloride < 0.1

Guanfacine Hydrochloride < 0.1

Oxazepam < 0.1

Olanzapine Fluoxetine Hydrochloride c < 0.1

Clozapine  < 0.1

Perphenazine  < 0.1

Phenobarbital  < 0.1

Valproic Acid  < 0.1

Imipramine Pamoate  < 0.1
Appendix II: Formulary Comparison

Page 39 GAO-13-26 DOD and VA Health Care

Medication on DOD’s formularya Medication on VA’s 

formulary

Percentage of DOD 

prescriptions filled 

by active duty 

servicemembers, 

fiscal year 2011

Phenytoin  < 0.1

Protriptyline Hydrochloride < 0.1

Vilazodone Hydrochloride < 0.1

Amitriptyline Hydrochloride 

Chlordiazepoxide c < 0.1

Paroxetine Mesylate  < 0.1

Loxapine Succinate  < 0.1

Lurasidone Hydrochloride < 0.1

Perphenazine Amitriptyline c < 0.1

Pimozide  < 0.1

Bupropion Hydrobromide  < 0.1

Thiothixene  < 0.1

Selegiline  < 0.1

Fluphenazine Hydrochloride  < 0.1

Valproate Sodium < 0.1

Maprotiline Hydrochloride < 0.1

Methamphetamine Hydrochloride < 0.1

Isocarboxazid < 0.1

Ethosuximide < 0.1

Lithium Citrate  < 0.1

Tranylcypromine Sulfate  < 0.1

Thioridazine Hydrochloride < 0.1

Trifluoperazine Hydrochloride  < 0.1

Clonidine Hydrochloride  < 0.1

Amoxapine < 0.1

Haloperidol Lactate  < 0.1

Clobazam 0.0

Ethotoin 0.0

Felbamate  0.0

Mephobarbital 0.0

Meprobamate 0.0

Methsuximide 0.0

Molindone Hydrochloride  0.0

Rufinamide 0.0
Appendix II: Formulary Comparison

Page 40 GAO-13-26 DOD and VA Health Care

Medication on DOD’s formularya Medication on VA’s 

formulary

Percentage of DOD 

prescriptions filled 

by active duty 

servicemembers, 

fiscal year 2011

Trimipramine Maleate 0.0

Vigabatrin 0.0

Subtotal psychiatric 99 62 (63%) 100%d

Pain 

Ibuprofen  27.8

Hydrocodone Bit Acetaminophen  14.0

Oxycodone Hydrochloride 

Acetaminophen  13.8

Naproxen  11.4

Tramadol Hydrochloride  6.5

Cyclobenzaprine Hydrochloride  6.5

Meloxicam  5.0

Celecoxib 2.7

Gabapentin  2.3

Acetaminophen With Codeine  2.0

Oxycodone Hydrochloride  1.7

Diclofenac Sodium  1.0

Indomethacin  0.8

Morphine Sulfate  0.5

Piroxicam  0.4

Naproxen Sodium  0.3

Hydromorphone Hydrochloride  0.3

Ketorolac Tromethamine  0.3

Etodolac  0.2

Tramadol Hydrochloride 

Acetaminophen 0.2

Buprenorphine Hydrochloride 

Naloxone  0.1

Diclofenac Epolamine 0.1

Fentanyl  0.1

Oxymorphone Hydrochloride 0.1

Hydrocodone Ibuprofen 0.1

Methadone Hcl  0.1

Nabumetone 0.1

Meperidine Hydrochloride  0.1
Appendix II: Formulary Comparison

Page 41 GAO-13-26 DOD and VA Health Care

Medication on DOD’s formularya Medication on VA’s 

formulary

Percentage of DOD 

prescriptions filled 

by active duty 

servicemembers, 

fiscal year 2011

Oxaprozin 0.1

Diclofenac Potassium  0.1

Sulindac  < 0.1

Diclofenac Sodium Misoprostol < 0.1

Diflunisal < 0.1

Tapentadol Hydrochloride < 0.1

Codeine Sulfate  < 0.1

Buprenorphine  < 0.1

Ketoprofen < 0.1

Tolmetin Sodium < 0.1

Salsalate  < 0.1

Dihydrocodeine Aspirin Caffeine < 0.1

Naproxen Esomeprazole Magnesium < 0.1

Buprenorphine Hydrochloride  < 0.1

Mefenamic Acid < 0.1

Butorphanol Tartrate  < 0.1

Codeine Butalbital Acetaminophen 

Caffeine < 0.1

Flurbiprofen  < 0.1

Morphine Sulfate/Naltrexone < 0.1

Pentazocine Hydrochloride Naloxone 

Hydrochloride < 0.1

Fentanyl Citrate  < 0.1

Dihydrocodeine Bitartrate 

Acetaminophen Caffeine < 0.1

Oxycodone Hydrochloride 

Oxycodone Terephthalate Aspirin < 0.1

Pentazocine Hydrochloride 

Acetaminophen < 0.1

Fenoprofen Calcium < 0.1

Ibuprofen Oxycodone Hydrochloride < 0.1

Meclofenamate Sodium < 0.1

Oxycodone Hydrochloride Aspirin < 0.1

Codeine Butalbital Aspirin Caffeine < 0.1

Choline Sal Magnesium Salicylate < 0.1

Levorphanol Tartrate < 0.1
Appendix II: Formulary Comparison

Page 42 GAO-13-26 DOD and VA Health Care

Medication on DOD’s formularya Medication on VA’s 

formulary

Percentage of DOD 

prescriptions filled 

by active duty 

servicemembers, 

fiscal year 2011

Meperidine Hydrochloride Prometh 

Hydrochloride < 0.1

Aspirin Codeine Phosphate < 0.1

Carisoprodol Codeine Phosphate 

Aspirin < 0.1

Ibuprofen Famotidine 0.0

Lansoprazole Naproxen 0.0

Magnesium Salicylate 0.0

Subtotal pain 65 31 (48%) 100%d

Total 164 93 (57%)

Source: GAO analysis of DOD and VA data.

a

This analysis does not include psychiatric or pain medications on DOD’s formulary that were 

available over-the-counter, were bulk medications used by pharmacists for compounding, and were 

provided through certain routes of administration, such as intravenous pain medications.

b

Prescriptions for phenytoin sodium extended includes prescriptions for phenytoin sodium.

c

VA generally does not include combination medications on its formulary. However, VA officials told 

us that their providers can prescribe several medications together, which can be equivalent to the 

combination medication. Therefore, in cases where VA’s formulary includes the individual 

medications that make up a particular combination medication, we have marked it as being on VA’s 

formulary.

d

Percentages do not sum to 100 due to rounding.
Appendix III: Comments from the Department 

of Defense

Page 43 GAO-13-26 DOD and VA Health Care

Appendix III: Comments from the 

Department of Defense
Appendix III: Comments from the Department 

of Defense

Page 44 GAO-13-26 DOD and VA Health Care
Appendix IV: Comments from the Department 

of Veterans Affairs

Page 45 GAO-13-26 DOD and VA Health Care

Appendix IV: Comments from the 

Department of Veterans Affairs
Appendix IV: Comments from the Department 

of Veterans Affairs

Page 46 GAO-13-26 DOD and VA Health Care
Appendix IV: Comments from the Department 

of Veterans Affairs

Page 47 GAO-13-26 DOD and VA Health Care
Appendix IV: Comments from the Department 

of Veterans Affairs

Page 48 GAO-13-26 DOD and VA Health Care
Appendix V: GAO Contact and Staff 

Acknowledgments

Page 49 GAO-13-26 DOD and VA Health Care

Debra A. Draper, (202) 512-7114 or draperd@gao.gov

In addition to the contact named above, Janina Austin, Assistant Director; 

Jennie Apter; Lisa Motley; Leslie Powell; Dan Ries; and Karin Wallestad 

made key contributions to this report.

Appendix V: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Staff 

Acknowledgments 

(291003)
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