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B-133142 1 (1974-11-11)

handle is hein.gao/gaobaaeqm0001 and id is 1 raw text is: o UNITED STATES GENERAL ACCOUNTING OFFICE OL ou WASHINGTON, D.C. 20548 MANPOWER AND WELFARE DIONOV 1 11974 B-133142 The Honorable James R. Cowan, M. D. J~~lJj 111111111111111 Assistant Secretary of Defense LM093086 (Health and Environment) Dear Dr. Cowan: Under the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), the Department of Defense pays for health care provided by civilian sources to dependents of act've duty and de- ceased military personnel and retired military personnel and their dependents. Program benefits include reimbursement for part of the cost of prescription drugs and insulin purchased on an outpatient basis. The cost to CHAMPUS for this outpatient drug program has in- creased from $256,000 for fiscal year 1967 to about $5 million for fiscal year 1973. Reimbursements for outpatient drugs are made by CHAMPUS fiscal agents on the basis of claims submitted by beneficiaries or by phar- macies. According to CHAMPUS officials, about 93 percent of the drug claims are submitted by beneficiaries and contain information on the identity and eligibility of the beneficiaries and copies of receipts from pharmacies. The receipts give the prescription numbers, dates of purchases, and prices but usually do not contain the name of the drugs purchased. Consequently, unless they obtain additional information from pharmacies, fiscal agents cannot identify claims for over-the- counter (non-prescription) drugs, which, with the exception of insulin, are not an authorized benefit. During a recent survey of the CHAMPUS program, we randomly selected a sample of prescriptions from beneficiary-submitted claims processed by the California fiscal agent for CHAMPUS during the period December 1972 through February 1973. We then obtained the name of the drugs purchased from the pharmacies who filled the prescriptions. We found instances where prescriptions were for over-the-counter drugs, such as vitamins and cough syrup, and the fiscal agent had reimbursed the beneficiary for such items. We noted that a fiscal agent in another State requested beneficiaries, when submitting drug claims, to provide additional information including the name of the drugs in order that over-the-counter drugs could be

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