DOD and VA Health Care: Actions Needed to Help Ensure Appropriate Medication Continuation and Prescribing Practices
Published: 2016-01-05T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Medication continuation, when clinically appropriate, is critical for transitioning servicemembers with PTSD or TBI who have been prescribed psychiatric, pain, or sleep medications. Adverse health effects may occur if these medications are inappropriately discontinued.
The National Defense Authorization Act for Fiscal Year 2015 included a provision for GAO to assess transitions of care, particularly medication continuation for servicemembers with PTSD or TBI transitioning to VHA. GAO examined (1) the extent to which DOD and VHA developed and monitored recommended medication practices for PTSD and TBI; (2) the extent to which psychiatric, pain, and sleep medications on DOD's formulary are on VA's formulary, and how differences might affect medication continuation; and (3) key efforts VHA has to help ensure medication continuation, and the extent it is monitoring these efforts. GAO reviewed documents and analyzed DOD and VHA data from fiscal years 2012 through 2015; and interviewed DOD and VHA officials from headquarters and five Army and DOD facilities, selected for variation in size and location. GAO focused on the Army as the largest number of its servicemembers served in recent conflicts.
section_title: What GAO Found
paragraphs: The Department of Defense (DOD) and the Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) have collaborated to develop clinical practice guidelines for post-traumatic stress disorder (PTSD) and mild traumatic brain injury (TBI). The mild TBI guideline does not include recommendations based on scientific evidence regarding the use of medications to treat symptoms because of a lack of available research; however, the PTSD guideline discourages the use of benzodiazepines (a sedative) and states that the use of antipsychotics to treat PTSD lacks support, based on available research. VHA monitors the prescribing of benzodiazepines and antipsychotics to treat PTSD nationally and by VA medical centers (VAMC) and requires VAMCs to implement improvement plans if their prescribing is significantly higher than the average of all VAMCs. GAO found that DOD relies on each military service to review the medication prescribing practices of its providers and that the Army does not monitor the prescribing of medications to treat PTSD on an ongoing basis. Without such monitoring, the Army may be unable to identify and address practices that are inconsistent with the guideline. Federal internal control standards require agencies to have control activities to establish performance measures, implement ongoing monitoring to assess performance, and ensure that the findings of reviews are promptly resolved.
As of August 2015, VA's formulary included 57 percent of the psychiatric, pain, and sleep medications on DOD's formulary. These medications are prescribed to treat symptoms common among servicemembers and veterans with PTSD or mild TBI, and most of the DOD prescriptions in fiscal year 2014 for these medications (88 percent) were on both formularies. In addition, DOD and VHA officials GAO interviewed agreed that the differences did not affect the continuation of medications for servicemembers transitioning from DOD to VHA.
VHA has two key efforts to help ensure continuation of medications for transitioning servicemembers, including those with PTSD or mild TBI, but a lack of clarity of one effort may limit its effectiveness. VHA's nonformulary request process is one key effort that helps ensure newly transitioned veterans avoid medication discontinuations due to differences between the DOD and VA formularies. VHA monitors nonformulary requests. VHA data show that 81 percent of requests submitted from fiscal years 2012 through 2014 were approved, and 98 percent of requests were adjudicated within VHA's required time frame of 96 hours. The other key effort is VHA's 2015 policy instructing its providers not to discontinue mental health medications initiated by DOD providers due to formulary differences. However, VHA providers GAO interviewed had varying interpretations of which medications are covered by this policy, and VHA officials acknowledged that the definition of a mental health medication could be subjective. Federal internal control standards state that agencies should establish control activities, such as developing clear policies. Because VHA's policy lacks clarity, VHA providers may be inappropriately discontinuing mental health medications due to formulary differences, which could increase the risk of adverse health effects for transitioning servicemembers.
section_title: What GAO Recommends
paragraphs: GAO recommends that the Army monitor prescribing practices of medications discouraged under the PTSD guideline and that VHA clarify its medication continuation policy. DOD and VHA concurred with the recommendations.

section_title: Letter
paragraphs: Post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI) are  two of the most prevalent injuries occurring as a result of military  operations in Afghanistan and Iraq. Servicemembers diagnosed with  PTSD or TBI, which is classified as mild, moderate, or severe, are treated  with various therapies to manage their symptoms. These therapies may  include psychiatric, pain, and sleep medications to manage symptoms  such as irritability, insomnia, and headaches. If these medications are  abruptly changed or discontinued, adverse health effects may occur. For  example, a servicemember with PTSD whose symptoms of outbursts and  self-destructive behavior have been stabilized with a psychiatric  medication may experience a return of symptoms or withdrawal effects if  the medications are suddenly stopped. A servicemember could also  experience the onset of new side effects when initiating a new  medication.
Effective medication management, which includes ensuring that  medication regimens are continued when clinically appropriate, is critical  for servicemembers with PTSD or TBI who transition their health care  from the Department of Defense (DOD) to other health care systems,  including the one operated by the Department of Veterans Affairs’ (VA)  Veterans Health Administration (VHA). In particular, some stakeholders  have raised concerns that VHA providers may change or discontinue  servicemembers’ medications upon transition to VHA because the VA  formulary includes fewer medications than the DOD formulary. Further,  some stakeholders have recommended that DOD and VA have a single  formulary to better ensure medication continuation for transitioning  servicemembers.
The Carl Levin and Howard P. “Buck” McKeon National Defense  Authorization Act for Fiscal Year 2015 included a provision for us to  assess the transition of care, particularly with respect to medications, for  servicemembers with PTSD or TBI as they transition from DOD to VHA.  This report examines  1.  the extent to which DOD and VHA have developed and monitored  recommended medication practices for PTSD and TBI;  2.  the extent to which psychiatric, pain, and sleep medications on DOD’s  formulary are also on VA’s formulary, and how, if at all, any  differences have affected the continuation of medications for  servicemembers transitioning from DOD to VHA; and  3.  key efforts, if any, VHA has in place to help ensure the continuation of  medications for servicemembers transitioning from DOD to VHA, and  the extent to which VHA is monitoring these efforts.
To determine the extent to which DOD and VHA have developed and  monitored recommended medication practices for PTSD and TBI, we  reviewed documents and interviewed officials from DOD, the Department  of the Army, and VHA. We focused our review of DOD’s monitoring  efforts on the Army because, compared to the other military services, it  has the largest number of servicemembers who served in military  operations in Iraq and Afghanistan, placing them at increased risk for  having PTSD or TBI. We further focused our review on mild TBI because  these patients are typically treated on an outpatient basis while patients  with more severe TBI are treated in inpatient settings and medication  discontinuation in outpatient settings may be especially challenging. We  reviewed documents, such as the VA/DOD clinical practice guidelines for  management of PTSD and mild TBI, and department policies and  program documents related to medication treatments and monitoring  efforts, including reports summarizing the prescribing of medications to  treat servicemembers and veterans with PTSD. We interviewed officials  from DOD, Army, and VHA headquarters to obtain information about  recommended medication practices for patients with PTSD or mild TBI  and monitoring efforts to help ensure that providers are following these  practices. Specifically, for DOD, we interviewed officials from the Office of  the Assistant Secretary of Defense for Health Affairs (Health Services  Policy and Oversight), the Defense and Veterans Brain Injury Center  within the Defense Centers of Excellence for Psychological Health and  Traumatic Brain Injury, and the Defense Health Agency Pharmacy  Operations Division. For the Army, we interviewed officials from the Office  of the Surgeon General Behavioral Health Service Line and Traumatic  Brain Injury Program, Medical Command Evidence-Based Practice Office,  and the Pharmacovigilance Center. For VHA, we interviewed officials  from the National Center for PTSD; Office of Mental Health Operations;  Office of Quality, Safety, and Value Evidence-Based Clinical Practice  Guidelines Program; Pharmacy Benefits Management Services; Pain  Management Program; and Polytrauma System of Care at the Richmond,  Virginia VA Medical Center (VAMC). We interviewed pharmacists,  psychiatrists, and other providers who treat patients with PTSD or mild  TBI about the recommended medication practices and related monitoring  at three VAMCs located in Washington, D.C.; Boise, Idaho; and  Tuscaloosa, Alabama; and two Army military treatment facilities (MTF)  located in Fort Hood, Texas and Fort Carson, Colorado. We selected the  VAMCs and Army MTFs for variation in size and geographic location. As  part of our review, we examined the extent to which the Army’s and  VHA’s efforts were consistent with the standards for internal control in the  federal government—specifically those related to control activities and  monitoring.
To determine the extent to which the psychiatric, pain, and sleep  medications on DOD’s formulary are also on VA’s formulary and how, if at  all, any differences have affected the continuation of medications for  servicemembers transitioning from DOD to VHA, we conducted a  comparison of the two formularies and interviewed DOD and VHA officials  and stakeholders for their perspectives on any differences. We selected  these three categories of medications because they are used to treat  symptoms that are common among patients with PTSD or mild TBI.  DOD’s Pharmacy Operations Division identified the psychiatric, pain, and  sleep medications on DOD’s formulary as of August 2015. We compared  the active pharmaceutical ingredients on this list with those on the VA  formulary as of August 2015, as provided by VHA. Because we focused  on transitions of care from DOD to VHA, we did not determine which  medications on VA’s formulary were not on DOD’s formulary. To provide  further context to our formulary comparison, we analyzed DOD’s  utilization of the medications on its formulary. We obtained data from  DOD on the number of prescriptions filled by DOD for active duty  servicemembers in fiscal year 2014, the most recent year of complete  data available, for each of the psychiatric, pain, and sleep medications on  its formulary. We spoke with knowledgeable DOD officials about the  formulary and prescription data, including their methodology for  identifying pain, psychiatric, and sleep medications, and as a result, DOD  made several modifications to its final list of medications. We also spoke  with DOD and VHA officials about our methodology for comparing the  formularies. On the basis of these discussions, we determined the data to  be sufficiently reliable for the objectives of our report.
We also interviewed DOD and VHA officials about the reasons for, and  potential implications of, identified formulary differences. In addition, we  reviewed analyses conducted by VHA and other organizations on the  possible implications of formulary differences, including the extent to  which differences may have affected medication continuation. We also  obtained the perspectives of providers and pharmacists from our selected  VAMCs and Army MTFs, as well as case managers who help manage  and transition the health care of servicemembers and veterans with  complex needs. In addition, we interviewed seven stakeholder groups— American Legion, Iraq and Afghanistan Veterans of America, Military  Officers Association of America, three Vet Centers (associated with the  three VAMCs included in our review), and the Military Compensation and  Retirement Modernization Commission.
To identify the key efforts, if any, VHA has in place to help ensure the  continuation of medications for servicemembers transitioning from DOD  to VHA and to determine the extent to which VHA is monitoring these  efforts, we interviewed VHA officials and reviewed related VHA  documentation and data. Specifically, to determine how VHA providers  prescribe medications that are not on VA’s formulary to servicemembers  transitioning from DOD, we reviewed VHA policy documents and  interviewed VHA officials, providers and pharmacists from our three  selected VAMCs, and the Veterans Integrated Service Networks (VISN)  for the VAMCs in our review. We obtained data, from fiscal years 2012  through 2014, from VHA on medications that were not on VA’s formulary  that VHA providers requested, and we analyzed the data to determine the  percentage of such requests that were approved and the extent to which  these requests were adjudicated in a timely manner. We also obtained  data on VHA’s prescription rates for fiscal year 2014 for the top five  psychiatric, pain, and sleep medications prescribed by DOD that were not  on VA’s formulary to determine the extent to which VHA prescribes  medications that are not on the formulary. Based on our discussions with  VHA, VISN, and VAMC officials about how prescription data and requests  for medications not on the VA formulary are collected, analyzed, and  reported, we determined the data to be sufficiently reliable for the  objectives of our report. In addition, we interviewed VHA officials to  identify policies related to continuation of medications for transitioning  servicemembers and reviewed those policies, including the extent to  which VHA monitors their effectiveness. As part of our review, we  examined the extent to which VHA’s policies and monitoring efforts were  consistent with the standards for internal control in the federal  government—specifically those related to control activities and  monitoring.
We conducted this performance audit from May 2015 to December 2015  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.
subsections: section_title: Background
subsections: section_title: DOD and VHA Health Care
paragraphs: DOD and VHA provide health care, including medications for psychiatric,  pain, and sleep conditions, to servicemembers and veterans through their  respective health care systems. DOD provides health care to active duty  servicemembers; Reserve and National Guard members on active duty;  and other beneficiaries, such as family members and retired  servicemembers, through TRICARE, its health care program. TRICARE  beneficiaries can obtain comprehensive health care services—including  outpatient and inpatient care, mental health care, and prescriptions for  medications—through a direct-care system of MTFs operated by the  Departments of the Army, Navy, and Air Force, or through a purchased- care system of civilian health care providers. Prescription medications  can be obtained through MTF pharmacies, 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 certain classes of medications, such as weight-loss  medications, DOD makes all Food and Drug Administration-approved  prescription medications available. DOD’s formulary process is  administered by DOD’s Pharmacy and Therapeutics Committee, and the  formulary includes a list of medications that all MTFs must provide and  medications that an MTF may elect to provide on the basis of the types of  specialized services that the MTF offers (such as cancer medications).  DOD classifies certain medications as “nonformulary” on the basis of its  evaluation of their cost and clinical effectiveness, and DOD’s  nonformulary classification applies to all MTFs and DOD’s purchased- care system. Nonformulary medications are available to beneficiaries at a  higher cost, unless the provider can establish medical necessity.
Veterans who served in active military duty, and were discharged or  released under conditions other than dishonorable are generally eligible  for VHA health care. In general, veterans must enroll in VHA health care  to receive VHA’s medical benefits—a set of services that includes a full  range of hospital and outpatient services, mental health care, and  prescription medications. VHA provides health care services at various  types of facilities, including VAMCs and community-based outpatient  clinics. Veterans may obtain prescription and over-the-counter  medications through VAMC or community-based outpatient clinic  pharmacies, VHA’s mail-order pharmacy, or through certain non-VHA  pharmacies. VA’s formulary provides access to medications for eligible  beneficiaries. VHA manages VA’s formulary and makes decisions about  whether to add medications to the formulary on the basis of clinical and  cost effectiveness and, like DOD, provides access to nonformulary  medications when providers establish medical necessity. Because VHA  only fills prescriptions written by VHA providers or providers VHA has  authorized its patients to see, VHA generally has direct control over the  medications that are prescribed to its patient populations.
section_title: PTSD and Mild TBI
paragraphs: PTSD is a trauma and stressor-related disorder that can occur after a  person is exposed to a traumatic or stressful event such as a death or  serious injury; its onset may be delayed. As defined in the fifth edition of  the Diagnostic and Statistical Manual of Mental Disorders, to be  diagnosed with PTSD, patients must have experienced four types of  symptoms that continue for more than 1 month after the event: persistently re-experiencing the event such as through flashbacks persistently avoiding trauma-related stimuli such as places or  situations that are reminders of the event; negative changes in cognitions and mood that began or worsened  after the event, such as persistent negative beliefs about oneself or  the world; and changes in arousal and reactivity that may include aggressive or  self-destructive behavior and insomnia.
The symptoms cause significant distress or impairment—for example, in  the patient’s social relationships and work life—and the duration of  symptoms varies, according to the Diagnostic and Statistical Manual of  Mental Disorders. That is, some patients with PTSD have symptoms for  less than 3 months while others may experience symptoms for longer  than a year and sometimes for many years. In addition to providing  medication therapy, DOD and VHA provide psychotherapy, which has  been shown to be effective in the treatment of PTSD in clinical research  studies, as well as other types of therapies.
Mild TBI (also known as a concussion) is caused by a blow or jolt to the  head that temporarily disrupts the normal function of the brain. The  diagnosis is based on several factors including that the patient has an  alternation of consciousness that may last from a moment up to 24 hours  or has a loss of memory for the events immediately before or after the  injury that lasts for a day or less. There are many causes of this  condition—such as blasts and car accidents—and, while not all patients  with mild TBI have symptoms, those that do typically experience  symptoms immediately following the event. Headache is the most  common symptom, and other common symptoms include dizziness,  fatigue, irritability, and insomnia. A very small proportion of patients with  mild TBI have symptoms that persist beyond 6 months, although  symptoms may last longer after repeated mild TBIs. In addition to  providing medication therapy for certain symptoms, DOD and VHA  provide other services for the treatment of mild TBI symptoms which may  include physical and occupational therapy and neuropsychological care.  Servicemembers that are diagnosed with mild TBI as a result of combat  also have a higher risk of experiencing PTSD. Additionally,  servicemembers with either PTSD or mild TBI often experience other co- occurring conditions, such as chronic pain, which may be related to their  combat-related injuries.
section_title: Medication Management and Continuation during Transitions of Care
paragraphs: As we previously have reported, the length of time that servicemembers  take to transition their health care from DOD to VHA or another health  care system varies. Some servicemembers may not transition their care  to VHA at all and instead seek care from other health care systems and  providers. Of those transitioning to VHA, some servicemembers separate  from the military and have their first appointment at VHA the following  week. Others may take more time to transition to VHA, waiting months or  years before scheduling their first appointment.
Effective transitions of care, including for servicemembers transitioning  from DOD to VHA, should include education and counseling about  medication adherence, medication lists at discharge, and a plan for how  to get medications during transitions, according to the National  Transitions of Care Coalition—a nonprofit organization that produces  tools and resources to assist with such transitions. As we previously have  reported, DOD and VHA have established several programs to assist  servicemembers, such as those with PTSD or mild TBI, with care  transitions, including help with medication management. For example,  Army nurse case managers have procedures both to assess if  servicemembers receiving care at MTFs have sufficient supplies of  medications until their initial VAMC appointment and to share  servicemembers’ medication lists with VA liaisons. VA liaisons, who are  nurses or social workers stationed at MTFs, in turn, have procedures to  ensure that VHA providers receive servicemembers’ medication lists and  that transitioning servicemembers have adequate supplies of medications  until their initial appointments. Another example is DOD’s inTransition  Program. The inTransition Program is a confidential personal coaching  program that helps servicemembers with mental health conditions as they  move between health care systems or providers. The inTransition  Program coaches are social workers who encourage transitioning  servicemembers with mental health needs to continue their medications.  The continuation of medication therapy, that is, prescribing the same  medications when a servicemember separates from DOD and transitions  to other health care systems including VHA, is another important element  of effective care transitions. Continuing clinically appropriate medications  during this transition is especially important for servicemembers and  veterans with mental health or pain conditions, such as PTSD, whose  symptoms may have been stabilized as a result of medications that DOD  providers have prescribed. The treatment of symptoms with medications  can enable patients with mental health conditions to return to near-normal  functioning and can enhance the effectiveness of psychotherapy.
section_title: DOD and VHA Have Developed Medication Treatment Recommendations for PTSD and Mild TBI and VHA Monitors the Prescribing of Certain Medications for PTSD
subsections: section_title: DOD and VHA Have Collaborated to Develop Clinical Practice Guidelines for Medication Treatment for PTSD and Mild TBI
paragraphs: DOD and VHA have jointly developed clinical practice guidelines related  to PTSD and mild TBI, which include recommendations for the treatment  of symptoms among servicemembers and veterans with these  conditions. Each guideline includes a discussion of, and  recommendations on, management of care for servicemembers and  veterans with these conditions, such as screening and diagnosis, types of  treatment interventions, and assessing treatment responses. The PTSD  clinical practice guideline includes evidence-based recommendations to  assist DOD and VHA clinicians in their decision making about which  medications to prescribe to treat the symptoms of PTSD. The mild TBI  clinical practice guideline also includes recommendations related to  medications for treating the symptoms of the condition; these  recommendations are based on expert opinions, rather than evidence- based research, because of the lack of published studies on mild TBI  medication treatments. The guidelines state that the recommendations  should not prevent providers from using their own clinical expertise in the  care of an individual patient and should never replace sound clinical  judgment. In addition to providing guidance for clinical decision making,  the guidelines are intended to help improve the quality and continuum of  care and the health outcomes for servicemembers and veterans with  PTSD and mild TBI.
The PTSD guideline recommends that patients with PTSD be offered  certain types of antidepressants and discourages the use of  benzodiazepines, a type of sedative. According to the guideline, the use  of selective serotonin reuptake inhibitors or serotonin norepinephrine  reuptake inhibitors (types of antidepressants) are strongly recommended  because there is good evidence that they are effective in reducing the  core symptoms of PTSD and are generally well tolerated by  servicemembers and veterans with PTSD. In contrast, the guideline  states that the use of benzodiazepines should be discouraged because of  their lack of effectiveness in treating PTSD and because the risks may  outweigh potential benefits. The guideline also states that there is  evidence to suggest that benzodiazepines may worsen recovery and,  once they are initiated, they can be very difficult to discontinue due to  significant withdrawal symptoms.
Additionally, the guideline states that the use of antipsychotics (atypical  and conventional) to treat PTSD is not supported because the existing  evidence is insufficient to warrant their use. The guideline specifically  recommends against the use of one atypical antipsychotic (risperidone) to  supplement the use of antidepressants in treating PTSD, based on  evidence from a VA study. This study showed that risperidone did not  reduce the symptoms of PTSD and its use did not justify the risk for  adverse events.
The mild TBI guideline provides general guidance on medications for  treating the condition’s symptoms and on those medications that warrant  particular caution, including antipsychotics and benzodiazepines.  According to the guideline, there is insufficient evidence for  recommending the use of one medication over another to treat the  symptoms of mild TBI. As a result, the guideline provides general  recommendations about medications, such as ibuprofen or naproxen— nonsteroidal anti-inflammatory medications—that may be used to treat  common symptoms, such as tension headaches that occur periodically.  Because some patients with mild TBI may experience seizures and  confusion, the guideline cautions against the use of medications that can  increase a patient’s susceptibility to seizures, including antipsychotics,  and medications that can cause confusion, such as benzodiazepines.  Further, the use of medications to treat the condition itself (brain injury) is  not recommended since the Food and Drug Administration had not  approved any medications for this purpose as of April 2009, as stated in  the guideline.
The PTSD and mild TBI guidelines also include clinical guidance for  treating insomnia and pain in servicemembers and veterans with these  conditions. The guidelines emphasize that, when possible, initial  treatment for insomnia should begin with nonmedication options, and  recommend treatments, such as good sleep hygiene practices and  cognitive behavioral therapy. Should medications also be needed, the  guidelines state that insomnia may be treated with the use of certain  sleep medications that are not benzodiazepines, such as zolpidem. For  pain, the guidelines recommend individualized treatment plans tailored to  the types of pain the patient is experiencing. If medications are included  in the treatment plans, the guidelines recommend, for example, that non- steroidal anti-inflammatory medications be used to treat pain resulting  from injuries to the bones and muscles. The PTSD guideline further  recommends that providers prescribe low doses of opioids or other  centrally acting pain medications (which reduce the transmission of pain  through the brain), if required, and only in the short term, because they  can cause confusion, and then transition their patients to the use of non- steroidal anti-inflammatory medications.
section_title: VHA Monitors the Prescribing of Medications to Treat PTSD, but DOD and the Army Do Not; None Monitor Mild TBI Medications Given Lack of Specific Medication Recommendations in Mild TBI Clinical Guideline
paragraphs: VHA monitors the prescribing of medications that are included in the  PTSD guideline, but DOD and the Army do not monitor such prescribing  among servicemembers. As part of its Psychotropic Drug Safety Initiative,  which began in 2013, VHA tracks the prescribing of benzodiazepines,  antipsychotics, and other psychiatric medications to treat veterans with  PTSD. VHA tracks the prescribing of these medications quarterly at the  VAMC, VISN, and national levels. Specifically, VHA tracks the percentage  of veterans with PTSD who have been prescribed: (1) a benzodiazepine,  (2) an antipsychotic (atypical and conventional) without a separate  diagnosis of severe mental illness, and (3) medications from certain  classes of psychiatric medications for 60 days or more.
As part of the Psychotropic Drug Safety Initiative, VHA requires each  VAMC to develop and implement a plan to improve on any measure for  which the individual VAMC was performing significantly below the  average of all VAMCs. This requirement encompasses measures focused  on reducing prescriptions for benzodiazepines, antipsychotics, and other  classes of psychiatric medications to treat veterans with PTSD. If a VAMC  does not have any measures that meet the criteria, VHA still requires the  VAMC to implement a plan to reduce prescriptions for psychiatric  medications based on at least one measure, such as the percentage of  veterans with PTSD who have been prescribed a benzodiazepine. In  2015, 22 VAMCs had developed plans to decrease the percentage of  veterans with PTSD who are prescribed benzodiazepines and 26 had  developed plans to decrease the percentage of veterans with PTSD who  are prescribed antipsychotics (without a diagnosis of severe mental  illness). Specifically, one VAMC created a clinical reminder in its  electronic medical record that is activated when a veteran with PTSD  (without a diagnosis of severe mental illness) is prescribed an atypical  antipsychotic. To order the prescription, the VHA provider must justify  why the medication is needed. This VAMC decreased the percentage of  veterans with PTSD who had been prescribed antipsychotics by almost  half, from 21.8 percent in 2013 to 11.5 percent in 2015. In addition to  continually monitoring these measures, VHA officials told us that they  review VAMCs’ improvement plans twice a year and provide VAMCs  feedback. As part of the initiative, VHA provides patient-level data to  VAMCs—such as information about each patient with PTSD who is  prescribed a benzodiazepine along with the name of the provider who  prescribed the medication—so that VAMCs can prioritize patients where  prescribing practices can be improved. In 2013, VHA also began tracking  annually the percentage of veterans with PTSD who are prescribed  antidepressants and other medications including prazosin—a medication  recommended for PTSD patients who experience nightmares—nationally  and by VISN, and the results are shared with VISN pharmacy executives,  who are responsible for tracking pharmacy and patient outcome data.
In addition, VHA has begun a program, known as Academic Detailing, to  make resources available to providers to assist them in incorporating  evidence-based recommendations in the treatment of veterans with  mental health conditions, including PTSD. In 2014, VHA developed a  guide for clinicians on treating PTSD patients that summarizes key  recommendations for medication treatment included in the PTSD  guideline and provides other information, such as guidance on how to  discontinue benzodiazepines by tapering their dosage over time. As part  of the program, pharmacists meet one-on-one with providers that have a  high proportion of patients who had been prescribed certain medications  (e.g., benzodiazepines, opioids) for whom there are significant safety  concerns, including risk for abuse, to identify and address any treatment  gaps, according to a VHA official. Each VISN is responsible for  implementing an Academic Detailing program and was required to have a  program in place by September 30, 2015. VHA officials told us that as of  October 2015, 6 of the 21 VISNs had fully implemented such a program.
In contrast to VHA, neither DOD nor the Army monitors the prescribing of  medications to treat servicemembers with PTSD in accordance with the  guideline recommendations, on an ongoing basis. DOD officials told us  that DOD relies on each military service to review the medication  prescribing practices of its providers and helps facilitate medication  reviews by generating reports for all MTFs that include a list of patients  who are prescribed multiple psychiatric and pain medications. DOD  officials also told us that they track the prescriptions of certain  medications included in the PTSD guideline, such as antipsychotics, by  individual military service but do not track prescriptions according to  PTSD diagnosis on an ongoing basis. We found that the Army also does  not monitor the prescribing of medications that are included in the  guideline recommendations on an ongoing basis. Instead, Army officials  told us they have emphasized the importance of the PTSD  recommendations in their recently issued policies and provider training.  Specifically, the Army issued a PTSD policy in 2012, reissued it in 2014,  and provided related training on the medication recommendations in the  guideline. The policy and training stated that prescribing benzodiazepines  to patients with PTSD should be avoided and that prescribing atypical  antipsychotics to patients with PTSD warrants caution, given concerns  with potential adverse health effects.
The Army issued a policy in 2012 that required MTFs to review their  prescribing practices for atypical antipsychotics, but the policy did not  apply to benzodiazepines, and it expired in 2014. Army officials stated  that they issued the policy on atypical antipsychotics given concerns that  these medications could be prescribed without sufficient clinical rationale  by providers in the treatment of PTSD but said that they do not plan to re- issue it. Providers and pharmacists we interviewed from one Army MTF  told us that they are continuing to conduct these reviews because they  identified a higher-than-expected prescribing rate and believe  improvements can be made with additional efforts, such as further  education of providers. In contrast, providers and pharmacists we  interviewed from another Army MTF said that they were no longer  conducting the reviews because the policy expired. Army officials told us  that they are focusing their monitoring efforts on the extent to which the  clinical outcomes among servicemembers with PTSD improve over time.  These officials added that they do not have the same level of concern  about atypical antipsychotic prescribing for patients with PTSD as they  did 5 years ago because they believe recent efforts to raise awareness  about prescribing antipsychotics for PTSD have been effective. After we  asked Army officials about the effects of the policy, they responded by  conducting an analysis, which showed that the proportion of  servicemembers with PTSD (without a separate diagnosis of severe  mental illness) prescribed atypical and other antipsychotics decreased by  almost half, from 19 percent in fiscal year 2010 to 10 percent in fiscal year  2014. Army officials stated that they could repeat their analysis, if needed,  but did not identify any specific plans to do so. They added that they  could similarly track the percentage of servicemembers with PTSD  prescribed a benzodiazepine using the same data source.
Although a decrease in the proportion of servicemembers prescribed  atypical antipsychotics is important, the Army’s lack of ongoing monitoring  of the prescribing of these medications may increase the risk that the  PTSD guideline recommendations are not effectively followed. Federal  internal control standards require federal agencies to have control  activities in place to establish and review performance measures over  time and then implement ongoing monitoring to assess the quality of  performance and ensure that the findings of reviews are promptly  resolved. Without ongoing monitoring of Army providers’ prescribing of  antipsychotics and benzodiazepines to servicemembers with PTSD, the  Army may be unable to identify and address prescribing practices that are  inconsistent with the guideline and do not have a clinical justification.
Neither VHA nor DOD and the Army monitor the prescribing of  medications to treat mild TBI because the mild TBI guideline does not  include specific medication recommendations. According to a VHA  official, VHA does not conduct such monitoring because mild TBI is  associated with a wide range of symptoms, and, thus, treatment regimens  need to be individualized based on each patient’s symptoms. In addition,  this official added that, in contrast to the PTSD guideline, the mild TBI  guideline does not recommend the use of a particular medication over  another and there are no strict contraindications for certain medications.  DOD officials told us that the individual military services have processes  in place to review the prescribing practices of its providers. Army officials  stated that the Army has procedures in place that may include the review  of medication prescribing decisions, including for mild TBI, such as peer  reviews that are part of the Army’s privileging process. Army officials  explained that each department within an Army MTF is responsible for  developing standards for their specialty and monitoring, for example,  whether providers follow related evidence-based medical practices, which  may include prescribing medications. Army officials also stated that they  are currently focusing their TBI monitoring efforts on tracking the clinical  outcomes of TBI patients and have begun to pilot this effort in the TBI  clinics at seven Army MTFs.
section_title: VA’s Formulary Included More than Half of the Psychiatric, Pain, and Sleep Medications on DOD’s Formulary; Officials Agree That Differences Do Not Affect Medication Continuation
paragraphs: Our review found that VA’s formulary included more than half of the  psychiatric, pain, and sleep medications on DOD’s formulary. These  medications are prescribed to treat symptoms that are common among  servicemembers and veterans with PTSD or mild TBI. DOD and VHA  officials we spoke with agreed that the formulary differences did not affect  the continuation of medications for servicemembers transitioning from  DOD to VHA. (See app. I for a complete list of the psychiatric, pain, and  sleep medications on the DOD and VA formularies, as well as information  on DOD prescriptions for these medications.) We also found that the vast  majority of these medications that were actually prescribed by DOD in  fiscal year 2014 were on both formularies. (See table 1.) Additionally,  we found the most agreement between the formularies for psychiatric  medications, with the medications on VA’s formulary representing 98  percent of the prescriptions that had been filled by DOD in fiscal year  2014.
VHA officials told us that clinical considerations and cost are factors in  determining whether to include a medication on the formulary.
Specifically, they said they first consider which medications are the safest  and most effective for treating each condition, and then they select the  most cost-effective options. As a result of this process, the VA formulary  includes fewer medications than DOD’s. For example, VHA officials told  us that VA’s formulary did not include the pain medication piroxicam  because the formulary already included safer alternatives. VHA officials  also said the VA formulary only included two sleep medications because  of concerns about the appropriateness of some sleep medications for the  treatment of insomnia. Further, VHA officials and providers noted that  sleep problems are often a symptom of other conditions, including those  related to mental health, and, therefore, treating the underlying condition  may also treat the insomnia. Rather than including more of these  medications on the VA formulary, VHA has developed evidence-based  clinical recommendations for treating insomnia, which includes off-label  use of other types of medications, such as antidepressants; over-the- counter medications, such as antihistamines; and nonmedication  treatments.
DOD and VHA officials told us they do not believe that the differences  between the formularies affected the extent to which VHA providers  continued medications prescribed by DOD providers, when clinically  appropriate. In support of this position, officials noted the results of VHA’s  2015 study on this issue. Specifically, VHA conducted this study to  assess the extent to which differences in the DOD and VA formularies  affected medication continuation and found that VHA providers  infrequently changed or discontinued medications for nonclinical reasons,  including formulary differences. As part of the 2015 study, VHA  pharmacists reviewed DOD and VHA data on a sample of 729  servicemembers who transitioned from DOD to VHA in 2013 with a  psychiatric, pain, or sleep medication to determine whether their  medications were changed by VHA providers upon transition. For the 167  servicemembers whose medications were changed or discontinued, VHA  pharmacists reviewed the individual medical records to determine the  reasons why. VHA determined that 24 servicemembers (3 percent of the  729 servicemembers reviewed) had psychiatric, pain, or sleep  medications that were changed or discontinued for nonclinical reasons,  which could include formulary differences, upon transitioning to VHA.
Consistent with the findings of the 2015 VHA study, providers,  pharmacists, and case managers we interviewed at three VAMCs and  two Army MTFs, as well as military and veterans’ stakeholder groups,  were generally unaware of specific instances of medications being  changed or discontinued for nonclinical reasons, including formulary  differences. Although VHA providers and pharmacists said that this type  of change could occur, they most commonly said that medications are  changed for clinical reasons, such as side effects, the medication not  working, interactions with other medications, and general disagreement  with the prior treatment approach. Additionally, several VHA providers we  interviewed said most of the psychiatric, pain, and sleep medications they  would want to prescribe are already on the VA formulary, and we found  that the majority of the medications providers said were not on the  formulary have recently been added. For example, duloxetine, an  antidepressant added to VA’s formulary in 2015, was a commonly  mentioned nonformulary medication during our interviews with providers.
Given the differences in the formularies, some stakeholders have  suggested that DOD and VA establish a single formulary. The  advantages and disadvantages of doing so would depend, in part, on the  resulting formulary—that is, whether VA adopts all of the medications on  DOD’s formulary or, instead, VA and DOD agree to a new list of  medications. When we discussed the concept of a single formulary with  officials, VHA officials expressed concern that adopting DOD’s formulary  could diminish elements of their formulary process that they believe are  important from a clinical and cost perspective. Specifically, VHA officials  told us that adopting DOD’s formulary would result in including  medications that VHA has determined to be less safe than other  alternatives. For example, the DOD formulary includes a recently Food  and Drug Administration-approved extended release opioid medication  associated with a greater risk of overdose, if used incorrectly, due to the  larger amount of the active ingredient present in the medication,  compared to some other pain medications (such as immediate release  opioids). VHA officials told us they decided not to include this medication  on the formulary, given its ongoing efforts to improve the safety of opioid  prescribing. In addition, the Congressional Budget Office estimated that  VA’s costs would increase if it were to adopt the psychiatric, pain, and  sleep medications on the DOD formulary. VHA officials explained that  they are able to control pharmacy costs by requiring providers to  prescribe the most cost-effective medications, unless there is a clinical  reason to prescribe something else. Clinical reasons could include  medication continuation or concerns about particular side effects for  certain patients.
A single formulary could also be achieved by DOD and VA collaboratively  selecting which medications to include. This approach could result in cost  savings for DOD if the new formulary excluded higher cost medications.  Although VHA officials told us they would be supportive of this approach,  DOD officials said they are not because they view it as a reduction of the  benefit that they currently provide, and believe it is important to have a  more comprehensive formulary to better accommodate prescriptions  written by civilian health care providers. In addition, DOD officials told us  that current law requires them to include all clinically appropriate Food  and Drug Administration-approved medications. DOD officials told us that  including more medications on the formulary is beneficial because  individual patients respond differently to different medications.
section_title: VHA Has Two Key Efforts to Help Ensure Continuation of Medications, but Lack of Clarity of One Effort May Limit Its Effectiveness
subsections: section_title: VHA’s Nonformulary Request Process Helps Ensure Continuation of Medications and Most Requests Are Adjudicated within 96 Hours and Approved
paragraphs: VHA’s nonformulary request process is one key effort that helps newly  transitioned veterans, including those with PTSD or mild TBI, avoid  medication discontinuations that could occur as the result of differences in  the DOD and VA formularies, according to providers we interviewed and  VHA documents we reviewed. Data provided by VHA show that the most  commonly DOD-prescribed psychiatric, pain, and sleep medications not  on the VA formulary are prescribed by VHA providers through this  process. According to VHA policy, providers may request a medication  not on the VA formulary by submitting a nonformulary request, which is  reviewed by a pharmacist. The pharmacist, in turn, either approves or  denies the request based on whether the provider has demonstrated that  there is a clinical necessity for the medication. To be approved, requests  for nonformulary medications must meet one of several clinical criteria.  For example, a request will be approved if the provider has documented  that the veteran has had an allergic reaction to a formulary medication.  The pharmacist who reviews the request must approve or deny it within  96 hours, and a provider may appeal a request that a pharmacist initially  denied.
VHA monitors the rates in which VAMCs approve nonformulary requests  and the extent to which they adjudicate the requests within the required  timeframe of 96 hours. VAMCs report data quarterly to VHA on the  number of nonformulary requests that their pharmacists approved and  denied, the number of denied requests that providers subsequently  appealed, and the number of appealed requests that were overturned.  VHA does not collect data on the reasons why pharmacists deny  nonformulary requests. VHA officials told us they do not collect such data  because the only reason for a denial is that the provider did not establish  clinical justification for the medication.
VAMCs also report to VHA the number of nonformulary requests that  pharmacists adjudicated outside of VHA’s required 96-hour timeline. For  nonformulary requests that take longer than 96 hours to adjudicate,  VAMCs are required to report the reasons for the delayed adjudication.  For example, some of the reasons that VAMCs have reported include that  a request was referred to a specialist (e.g., a physician or another  pharmacist) for additional review and that the required documentation to  determine the appropriateness of the request (e.g., lab value) was  unavailable at the time of the request. VHA officials combine data from  VAMCs within each of the VISNs to report nonformulary request data  quarterly to VISN pharmacists. VHA officials told us they examine the  data, among other things, to identify outliers across VISNs related to the  number of nonformulary requests that take longer than 96 hours to  adjudicate, and they discuss these results during quarterly meetings with  VISN pharmacists who are responsible for overseeing the request  process with their respective VAMCs. For example, in 2013, VHA officials  identified a VISN with a relatively high number of nonformulary requests  with delayed adjudication and discussed this outlier at a meeting with  VISN pharmacists. This discussion led the VISN to implement several  changes that ultimately resulted in a lower number of requests with  delayed adjudication. Specifically, the VISN created an automated  nonformulary request form that tracks how long each request takes from  submission to adjudication. This change allows a provider that submits a  nonformulary request, as well as the pharmacists that review the request,  to be aware of requests that approach the required 96-hour timeframe for  adjudication.
VHA’s nonformulary request data show that pharmacists approved the  majority of the nonformulary requests that providers submitted from fiscal  years 2012 through 2014. Specifically, they approved 81 percent of the  2.1 million total nonformulary requests, or about 1.7 million, during this  time period. (See table 2.) Of the 19 percent of requests that were denied  (about 399,000), providers appealed 1 percent of these (about 4,600),  and most were overturned (61 percent). Providers we interviewed from all  three VAMCs told us that pharmacists approved the majority of  nonformulary requests they submitted.
Further, the vast majority of nonformulary requests that providers  submitted from fiscal years 2012 through 2014 were adjudicated within 96  hours. Of the approximately 2.1 million nonformulary requests that  providers submitted to pharmacists during this time, 98 percent were  adjudicated within 96 hours. Providers we interviewed from the three  VAMCs in our review told us that pharmacists adjudicated the majority of  their nonformulary requests within the required timeframe, and several  providers said they frequently received decisions on their requests within  1 or 2 hours of submitting them and sometimes sooner if they spoke  directly with a pharmacist about the request. The VHA data also showed  that the vast majority of requests that providers appealed were  adjudicated within the required timeline of 96 hours (91 percent) from  fiscal years 2012 through 2014. Of the nonformulary requests that took  longer than 96 hours to adjudicate, three pain medications and one  psychiatric medication were among the most frequently requested  medications by providers. However, the extent to which requests for  these four medications were ultimately approved or denied is unknown  because VHA officials do not separately track the results of nonformulary  requests for specific medications, including those taking longer than 96  hours to adjudicate.
section_title: VHA Issued a Policy to Help Ensure Continuation of Certain Medications for Transitioning Servicemembers, but It Lacks Clarity
paragraphs: VHA issued a policy in January 2015 that instructs providers not to  discontinue mental health medications initiated by DOD providers due to  differences in the DOD and VA formularies; another key effort to help  ensure medication continuation. VHA officials said that the reason for  issuing this policy was to provide added assurance that patients with  mental health conditions—who are among the most vulnerable—would  not have their mental health medications changed or discontinued for  nonclinical reasons upon transitioning from DOD to VHA. However, the  policy lacks clarity regarding which types of medications should be  considered mental health medications and, therefore, are not to be  discontinued. Specifically, the policy is unclear on whether providers  should continue (when clinically appropriate) all of the medications  prescribed by DOD providers for patients with mental health conditions or  only the psychiatric medications (such as antidepressants) that were  prescribed specifically to treat their mental health condition.
As pain and sleep medications treat symptoms that are commonly  experienced by patients with mental health conditions, such as PTSD,  VHA providers and pharmacists we interviewed had varying  interpretations of whether these medications would be considered mental  health medications under the new policy. For example, VHA providers  had different interpretations about whether they should continue  eszopiclone, a medication for the treatment of insomnia which is on  DOD’s formulary, but not VA’s. Some VHA providers said they would  have to switch medications for patients who transition from DOD on this  medication to one on the VA formulary, unless there is a clinical reason  not to do so. Other VHA providers said that the policy could cover other  types of medications prescribed to patients with mental health conditions,  such as sleep medications. In addition, in our review of VHA’s 2015 study  of transitioning servicemembers, we found that among the 24  servicemembers whose medications were changed or discontinued for  nonclinical reasons, more than half of them (13 of 24) had a pain or sleep  medication changed.
VHA officials acknowledged that the definition of a mental health  medication could be subjective and that they intended the policy to be  broad and to apply to any medication that is prescribed to treat a mental  health condition. Therefore, they stated that pain and sleep medications  should be considered mental health medications under the policy.  However, they also noted that some pain and sleep medications are not  intended for long term use, so providers may choose to discontinue  prescribing them for clinical reasons.
Given that VHA’s policy lacks clarity regarding which types of medications  should be considered mental health medications, VHA providers may be  inappropriately changing or discontinuing mental health medications due  to formulary differences. Such changes could lead to adverse health  effects, such as exacerbation of symptoms or new side effects. This lack  of clarity in VHA’s policy is inconsistent with federal internal control  standards, which state that agencies should establish control activities,  such as developing clear policies, in order to accomplish the agency’s  objectives.
VHA officials told us that they are planning to conduct another study of  transitioning servicemembers to determine if the new policy is having the  intended effect. Specifically, VHA officials told us that they plan to review  the prescriptions of about 5,000 servicemembers who transitioned from  DOD to determine whether their medications were continued at VHA  when clinically appropriate. VHA officials told us that they have been  working with DOD officials to obtain the data needed to conduct this  study.
section_title: Conclusions
paragraphs: Servicemembers and veterans diagnosed with PTSD or mild TBI may  experience significant difficulties and impairments in their social  relationships and work life. VHA and DOD have jointly developed a  clinical practice guideline for PTSD patients that includes evidence-based  recommendations to aid clinicians in their decision making about which  medications to prescribe to treat the symptoms of PTSD. However, the  Army does not have a mechanism in place to monitor on an ongoing  basis whether MTFs are prescribing medications that are consistent with  these recommendations.
Ensuring that medication regimens are continued when clinically  appropriate is critical for servicemembers transitioning their health care  from DOD to VHA, including those with PTSD and mild TBI. We did not  find evidence that the differences in the DOD and VA formularies for  these medications result in the inappropriate discontinuation of  medications. Although VA’s formulary includes just over half of the  medications on the DOD formulary, those on both formularies represent  the most commonly DOD-prescribed psychiatric, pain, and sleep  medications. However, we found that VHA’s new policy to ensure the  continuation of mental health medications lacks clarity on the types of  medications considered mental health medications, and, as a result, VHA  providers may be inappropriately changing or discontinuing mental health  medications due to formulary differences, potentially increasing the risk of  adverse health effects for transitioning servicemembers.
section_title: Recommendations for Executive Action
paragraphs: We recommend that the Secretary of Defense direct the Secretary of the  Army to implement processes to review and monitor Army MTF  prescribing practices for medications discouraged under the PTSD  guideline and address identified deviations.
We recommend that the Secretary of Veterans Affairs direct the Under  Secretary for Health to clarify which types of medications are covered by  VHA’s January 2015 policy on medication continuation.
section_title: Agency Comments
paragraphs: DOD provided written comments on a draft of this report, which we have  reprinted in appendix II. In its comments, DOD agreed with our  conclusions and generally concurred with our recommendation. DOD  stated that any policy that it may issue related to the monitoring of  prescribing practices would be directed toward all of the military services.  DOD also provided technical comments, which we have incorporated in  the report as appropriate.
VA also provided written comments on a draft of this report, which we  have reprinted in appendix III. In its comments, VA agreed with our  conclusions and concurred with our recommendation. VA stated that it will  issue written guidance to its providers clarifying which types of  medications are covered by its 2015 policy on medication continuation,  with an estimated completion date of March 2016. VA also provided  technical comments, which we have incorporated in the report as  appropriate.
We are sending copies of this report to the appropriate congressional  committees, the Secretary of Defense, the Secretary of Veterans Affairs,  and other interested parties. In addition, the report will be available at no  charge on the GAO Web site at http://www.gao.gov.
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 IV.
section_title: Appendix I: Formulary Comparison
paragraphs: We found that the Department of Veterans Affairs (VA) formulary included  57 percent of the psychiatric, pain, and sleep medications on the  Department of Defense (DOD) formulary, as of August 2015, and these  medications represented the most frequently prescribed psychiatric, pain,  and sleep medications on the DOD formulary in fiscal year 2014. (See  table 3.)
For a sample of psychiatric, pain, and sleep medications included on both  the DOD and VA formularies and that were frequently prescribed by DOD  providers in fiscal year 2014, we also compared the specific formulations  that were available on each formulary. We conducted this supplemental  analysis because DOD and Veterans Health Administration (VHA)  officials told us that prescribing different formulations of the same  medication may have clinical significance for certain medications or  certain patients. Specifically, we reviewed differences in the medication  formulations according to their available dosage form (e.g., liquid or  tablet), modified release formulation (e.g., extended or immediate  release), salt form (e.g., hydrochloride or sulfate), strength, and also their  route of administration (e.g., oral or nasal). We selected the five  psychiatric and five pain medications most frequently prescribed and filled  by DOD for active duty servicemembers in fiscal year 2014 that were on  both DOD and VA formularies. For sleep, the VA formulary only included  two medications, so we reviewed the formulations for both.
We found that the VA formulary included all of the formulations that were  on the DOD formulary for 7 of these 12 medications. The formulation  differences for the remaining 5 psychiatric, pain, and sleep medications  resulted from differences in dosage form and modified release  formulation. That is, 2 of the 5 medications were available on the DOD  formulary but not the VA formulary in the liquid form, and the remaining 3  medications were available on the DOD formulary but not on the VA  formulary in the extended release form. For example, the DOD and VA  formularies both include immediate release formulations of the sleep  medication zolpidem, but the DOD formulary also includes the extended  release version. We obtained the perspectives of DOD and VHA officials  regarding the clinical significance of the formulation differences that we  observed, and they agreed that these differences were not generally  clinically significant and would only have implications for specific patients,  such as certain patients who cannot swallow pills and who would benefit  from the liquid forms. In addition, DOD and VHA officials both said that  the primary difference between immediate release and extended release  medications would be the frequency with which the patient needs to take  the medication, but there could be differences in their effectiveness for  certain patients. VHA officials noted that the formulations of medications  that are not included on the VA formulary are often those for which there  is a limited need in their patient population, but, in situations where these  specific formulations are clinically indicated, they would utilize the  nonformulary request process to prescribe that medication. DOD officials  agreed that some of the formulations not available on VA’s formulary are  often not clinically indicated.
section_title: Appendix II: Comments from the Department of Defense
section_title: Appendix III: Comments from the Department of Veterans Affairs
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Janina Austin, Assistant Director;  Jennie F. Apter; Pamela Dooley; Joshua D. Ferencik; Jacquelyn  Hamilton; Toni Harrison; Katie McConnell; and Daniel Ries made key  contributions to this report.