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Pharmacy Benefits

icon pill bottleBeneficiaries 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 program.

IMPORTANT NOTE: Prescription medication must be approved by the U.S. Food and Drug Administration (FDA) and must not be used in conjunction with any experimental program.

Information for CHAMPVA Beneficiaries

CHAMPVA beneficiaries who do not have other health insurance (OHI) with pharmacy coverage are able to use Meds by Mail for nonurgent, maintenance medications and a local pharmacy in the OptumRx network for other prescription medications. If you have Medicare Part D, even though it is primary to CHAMPVA, you are still able to use an OptumRx pharmacy, but you will not be able to use Meds by Mail. Be sure to tell your local pharmacy that you have both Medicare Part D and CHAMPVA-OCC.

Pharmacies that are a part of the OptumRx network will collect your 25% cost share/copay along with the annual deductible and send the claim to CHAMPVA-OCC for the remaining amount. If you have OHI that is not Medicare Part D, you can submit a paper claim to VHA Office of Community Care for the portion that is paid out of pocket.

Information on filing CHAMPVA claims can be found on CHAMPVA Claims–Information for Beneficiaries

Fact Sheet 01-05: CHAMPVA Pharmacy Benefits

Information for Spina Bifida and CWVV Beneficiaries

Spina Bifida and CWVV beneficiaries are able to use a local pharmacy in the OptumRx network and the Meds by Mail program to obtain their medications without a cost share/copay. Pharmacies that are a part of the OptumRx network will send the claim electronically to VHA Office of Community Care for payment.

CWVV beneficiaries can only use OputmRx to obtain prescriptions for their rated 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 it is related to their disability. If related, the beneficiary will be reimbursed and then will be able to use OptumRX for future refills of that medication. Each prescription must first be paid by the beneficiary and then reviewed in order to be considered for CWVV pharmacy benefits.

Using Meds by Mail (MbM)

Meds by Mail offers nonurgent, maintenance prescription medications delivered directly to your home. The best part of MbM is that there is NO cost share or copay, and no annual deductible. The medication is provided with 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 have been diagnosed with Hepatitis C, cancer, or another costly health condition, please contact Meds by Mail to see if your medication is available.

Additional information can be found at Meds by Mail

View a list of the top 200 medications available from Meds by Mail
(This list is only a small sample of the thousands of medications that are available to CHAMPVA beneficiaries.)

Using a Local Pharmacy

OptumRx (formerly Catamaran) is a pharmacy benefits manager that has contracted with the VHA Office of Community Care (OCC) to provide a retail pharmacy network that will electronically process pharmacy claims. There are over 65,000 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 medication and submit a claim to VHA Office of Community Care yourself.

To find a participating pharmacy near you, visit the OptumRx website and select the Preferred Pharmacy Finder link from the left-hand navigation menu. You can also print a temporary pharmacy ID card from the OptumRx beneficiary FAQ’s page, or by giving your local pharmacy the following information: RxBIN: 610593 | RxPCN: VA | RxGrp: HAC

OptumRx websiteOptumRx Beneficiary FAQs

Pharmacy Contacts

OptumRx Beneficiary Help Desk

888-546-5502
If a beneficiary, or authorized representative, needs assistance from OptumRx, please call this number. This is also the number to contact to order a pharmacy card.

OptumRx Pharmacy Help Desk

888-546-5503
Pharmacists who have questions or need assistance from OptumRx should use this number.

Meds by Mail-EAST
Dublin, GA

866-229-7389
8:00 a.m. to 5:30 p.m. Eastern Standard Time
Monday–Friday

Meds by Mail-WEST
Cheyenne, WY

888-385-0235
8:00 a.m. to 5:30 p.m. Mountain Standard Time
Monday–Friday

MbM Automated Prescription Refill Line

888-370-1699

CHAMPVA Call Center

800-733-8387
Please contact CHAMPVA directly for any questions regarding eligibility, or to update insurance information (including pharmacy coverage) on file with CHAMPVA.

Spina Bifida Call Center

888-820-1756
Please contact the Spina Bifida Health Benefits Program directly for any questions regarding eligibility.

Excluded Benefits

The products listed below are no longer covered by CHAMPVA. Please contact your health care provider to determine other treatment options. These lists should not be considered all-inclusive and may change at any time.

Effective September 1, 2015: Compound prescriptions containing any of the following ingredients are no longer a covered benefit.
Excluded Compound Ingredients
  • Baclofen Powder
  • Bupivacaine HCL Powder
  • Cyclobenzaprine HCL Powder
  • Diclofenac Sodium Powder
  • Ethoxy Diglycol Liquid
  • Flurbiprofen Powder
  • Fluticasone Propionate Powder
  • Gabapentin Powder
  • Ketamine HCL Powder
  • Ketoprofen Micronized Powder
  • Levocetrizine Dihydrocloride Powder
  • Lipoderm Base
  • Lipo-Max Cream
  • Lipopen Plus Cream
  • Lipopen Ultra Cream Base
  • Meloxicam Powder
  • Mometasone Furoate Powder
  • Nabumetone Micronized Powder
  • Pracasil TM-Plus Gel
  • Prilocaine HCL Powder
  • Resveratrol Powder
  • Spira-Wash Gel
  • Tramadol HCL Powder
  • Versapro Cream Base
  • Versatile Cream Base
Effective October 1, 2015: The following medications are no longer a covered benefit.
Excluded Medications
  • Cytra-2 (Citric Acid/Sodium Citrate)
  • Ascorbic Acid
  • Calcium Ascorbate
  • Citric Acid
  • Folbic
  • Folgard
  • Hemocyte-F
  • ICAR-C Plus SR
  • Iron
  • Midrin
  • Multigen Plus
  • Potassium Bicarbonate
  • Pyridoxine
  • Virt-Vite Forte
  • Vitamin C
  • Zinc

Right to Reconsideration

You and/or your provider have the right to request reconsideration. A written statement explaining your disagreement must be received within one year from the date of this notification. Please attach any pertinent documentation to support your claim, include a copy of this notification with your request

VHA Office of Community Care
ATTN: Appeals
PO Box 460948
Denver, CO 80246

If you have any immediate questions or concerns, please contact our Customer Service Center:
800-733-8387, Monday–Friday
8:05 a.m.–7:30 p.m., Eastern Standard Time

A written statement explaining your disagreement must be received within one year from the date of this notification

Include:

  • Any pertinent documentation to support your claim
  • A copy of this notification with your request