pharmacy benefits
Beneficiaries of the CHAMPVA, Spina Bifida and Children of Women Vietnam Veterans (CWVV) programs are provided pharmacy benefits through a local retail pharmacy or through our Meds by Mail (MbM) program.
information for champva beneficiaries
Eligible CHAMPVA beneficiaries who do not have other health insurance (OHI) with pharmacy coverage can use MBM for non-urgent maintenance medications. prescribed, maintenance medications will be mailed to your home. **refrigerated medications cannot be delivered to a PO Box or outside of the continental United States.
Reading: What pharmacy takes va insurance
You can use your local pharmacy in the optumrx network for other prescription drugs. Pharmacies that are part of the optumrx network will collect your 25% cost share/copayment along with the annual deductible and submit the claim to champva for the remaining amount.
if you have other health insurance with pharmacy coverage, including medicare part d, even if it’s champva primary, you can still use an optumrx pharmacy. be sure to tell your pharmacy that you have primary coverage for prescriptions and champva. In this case, you may not have a cost share if the drug is covered by your primary insurance and by Champva.
you can find information about filing champva claims at champva claim information for beneficiaries
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fact sheet 01-05: pharmaceutical benefits of champva
information for beneficiaries of spina bifida and cwvv
spina bifida and cwvv beneficiaries can use a local pharmacy in the optumrx network and the mail order drug program to get their medications with no cost share/copay. Pharmacies that are part of the optumrx network will submit the claim electronically to the vha community care office for payment.
cwvv recipients can only use oputmrx to obtain prescriptions for their classified disability or conditions related to their disability. the first time a prescription is received, the beneficiary must pay 100% out of pocket. the beneficiary must then submit a claim with medical documentation to show that it is related to their disability. if related, the beneficiary will be reimbursed and then be able to use optumrx for future refills of that drug. each prescription must first be paid for by the beneficiary and then reviewed to be considered for cwvv pharmacy benefits.
mail-order drug use (mbm)
meds by mail offers non-urgent maintenance prescription medications delivered right to your home. The great thing about mbm is that there is no cost sharing, no copay, and no annual deductible. the drug is provided at no out-of-pocket cost to you! meds by mail also offers certain specialty medications that could save you hundreds or even thousands of dollars. If you’ve been diagnosed with Hepatitis C, cancer, or another costly health condition, contact Meds by mail to see if your medication is available.
additional information can be found at meds by mail
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view a list of the top 200 medications available from meds by mail (this list is just a small sample of the thousands of medications that are available to champva recipients).
using a local pharmacy
optumrx is a pharmacy benefit manager that has contracted with vha’s office of community care (occ) to provide a network of retail pharmacies that will electronically process pharmacy claims. there are more than 66,000 pharmacies nationwide that participate in the optumrx network. If you go to a pharmacy that is not part of the optumrx network, you will have to pay the full cost of the drug and file a claim with the vha community care office yourself.
To find a participating pharmacy near you, visit the optumrx website and select the Preferred Pharmacy Finder link in the left navigation menu. You can also print a temporary pharmacy ID card from the optumrx Beneficiary FAQ page, or by providing your local pharmacy with the following information: rxbin: 610593 | rxpcn: goes | rxgrp:hac
excluded benefits
champva no longer covers the products listed below. contact your health care provider to determine other treatment options. These lists should not be considered exhaustive and may change at any time.
excluded compound ingredients
excluded drugs
right of reconsideration
You and/or your provider have the right to request a reconsideration. a written statement explaining your disagreement must be received within one year from the date of this notice. attach any relevant documentation to support your claim, include a copy of this notice with your application
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