VA Prescription Coverage Eligibility Explained (2024 Update)

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Hey Veterans, Brian Reese here, the VA Claims Insider, with everything you need to know about VA prescription coverage eligibility!

Whether you’re navigating the complexities of VA healthcare benefits for the first time or looking to understand how prescription co-payments work, this article is here to simplify it all for you.

From service-connected veterans to low-income qualifiers, we’ll break down every category of eligibility and give you the inside scoop on how to get your medications covered for free.

Let’s dive in!

Summary of Key Points

• Eligibility for Free VA Prescriptions: Includes veterans with service-connected disabilities rated at 50% or higher, low-income veterans, former POWs, catastrophically disabled veterans, those receiving Aid and Attendance or Housebound benefits, veterans receiving VA pensions, and veterans with specific conditions like ALS.

• VA Co-Payment Requirements: While some veterans qualify for free prescriptions, others may need to make co-payments based on their priority group and the type of medication.

• 2024 VA Co-Payment Tiers and Caps: Medication costs vary by tier. $0 for Tier 0, $5-$15 for Tier 1, $8-$24 for Tier 2, and $11-$33 for Tier 3. An annual co-pay cap of $700 applies.

• Filling VA Prescriptions at Walgreens and CVS: Veterans can fill VA prescriptions at Walgreens through the VA-Walgreens partnership, but CVS is not a VA prescription provider, though it is a Tricare network pharmacy.

Who is Eligible for Free VA Prescriptions?

The VA provides prescription benefits to veterans based on their service-connected disabilities, income level, and other criteria.

Here’s a breakdown of the categories of veterans who qualify for free VA prescriptions:

1. Disabled Veterans Rated 50% or Higher  

Veterans with service-connected disabilities rated 50% or more are eligible for free medications related to any condition. Those with lower ratings may still receive free prescriptions if they are for their service-connected conditions.

2. Low-Income Veterans

Veterans who meet certain income thresholds may qualify for free medications. The VA determines eligibility based on the veteran’s annual income and financial situation.

3. Former Prisoners of War (POWs)

All former POWs are eligible for free VA medications regardless of their income or disability status.

4. Catastrophically Disabled Veterans

Veterans who are determined by the VA to have a catastrophic disability can receive free prescriptions.

5. Veterans Receiving Aid and Attendance or Housebound Benefits

Veterans receiving these additional VA benefits are eligible for free medications.

6. Veterans Receiving VA Pension

Veterans who receive a VA pension can also access free prescriptions.

7. Veterans with Special Eligibility

Certain conditions such as ALS (Lou Gehrig’s disease) provide automatic eligibility for free prescriptions.

Are There Co-Payments for VA Prescriptions

While many veterans qualify for free prescriptions, others may need to make co-payments.

Here’s what you need to know based on VA healthcare priority groups 1-8:

Priority Groups 1-8

• Priority Group 1: Veterans in this group do not pay any co-payments for medications. You may be in this group if your service-connected disability is rated at 50% or more, if you are unemployable due to your service-connected disability, or if you have received the Medal of Honor.

• Priority Groups 2-8: Veterans in these groups may pay co-payments for medications prescribed for non-service-connected conditions and over-the-counter medications.

VA Prescriptions Co-Payment Tiers and Caps

The amount you pay depends on the tier of the medication and the supply amount:

• Tier 0: $0 for any supply.

• Tier 1 (Preferred Generic Medications): $5 for a 1-30 day supply, $10 for a 31-60 day supply, $15 for a 61-90 day supply.

• Tier 2 (Non-Preferred Generic Medications and Some Over-the-Counter Medications): $8 for a 1-30 day supply, $16 for a 31-60 day supply, $24 for a 61-90 day supply.

• Tier 3 (Brand Name Medications): $11 for a 1-30 day supply, $22 for a 31-60 day supply, $33 for a 61-90 day supply.

Co-pay Cap: Once you’ve been charged $700 in medication copays within a calendar year (January 1 to December 31), you won’t have to pay any more that year.

Note: VA co-pay rates adjust each year.

Can I Get Free VA Prescriptions Filled at Walgreens?

Yes, veterans can fill their VA prescriptions at Walgreens through the VA-Walgreens partnership program.

Here’s how it works:

1. Register with the VA: Ensure you’re enrolled in VA healthcare and have your prescription from a VA healthcare provider.

2. Visit Walgreens: Take your VA prescription to any Walgreens pharmacy. Inform the pharmacist that you’re a VA patient. If your prescriptions were being filled somewhere else, you’ll need to have them transferred to Walgreens. You can do that by calling your local Walgreens pharmacy and requesting a prescription transfer.

3. Billing: Walgreens will process your prescription through the VA, and eligible medications will be covered. You may still be responsible for co-payments based on your VA eligibility and income category. You need to give the Walgreen’s pharmacy some specific information for billing as follows:

• BIN: 003858

• PCN: A4

• ID: 1265949378

• Group: Veteran

Can I Get Free VA Prescriptions Filled at CVS?

No, as of 2024, CVS is not on the VA’s free prescription provider list.

If you attempt to fill a VA prescription at CVS, you will likely have to pay out of pocket unless you qualify under another government program like Tricare, which does include CVS as a network pharmacy.

Alternative Options for Filling VA Prescriptions:

• VA Pharmacies: Veterans can fill their prescriptions directly at VA pharmacies.

• Walgreens: Participates in the VA Community Care Network (CCN) and can fill VA prescriptions under the program.

• In-Network Retail Pharmacies: For urgent or emergency prescriptions, veterans can use in-network retail pharmacies listed in the VA Facility Locator.

Is Walgreens a Tricare Network Pharmacy?

Yes, Walgreens is a Tricare network pharmacy.

As of recent updates, Walgreens has rejoined the Tricare retail pharmacy network, making it one of the available options for Tricare beneficiaries to fill their prescriptions.  

This means that active-duty service members, their dependents, and retirees can utilize Walgreens for their prescription needs under the Tricare plan.

Why Choose Walgreens?

• Over 9,000 Locations: Nationwide coverage for easy access.

• Extended Hours: Many stores are open 24/7.

• Drive-Thru Service: Convenient drive-thru options at numerous locations.

• VA and Tricare Network: Ensures veterans, disabled veterans, military, and dependents can fill prescriptions easily.

Is CVS a Tricare Network Pharmacy?

Yes, CVS is a Tricare network pharmacy, providing additional convenience for the military and veteran community.

This means that Tricare beneficiaries can fill their prescriptions at any CVS Pharmacy, enhancing access to essential medications for service members, veterans, and their families.

Why Choose CVS?

• Over 10,000 Locations: Including convenient locations inside Target stores.

• Extended Hours: Many stores are open 24/7 to fit your schedule.

• Drive-Thru Service: Thousands of locations offer drive-thru service for added convenience.

• Tricare Network: Serves the military and veteran community. Note: CVS does not accept VA insurance for prescriptions. You’ll need to fill your prescriptions either at the VA or at Walgreens.

How Do CHAMPVA Prescriptions Work?

The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) provides healthcare benefits to eligible beneficiaries.

Here’s an overview of how prescriptions are covered under CHAMPVA:

CHAMPVA Prescription Coverage Explained

Pharmacy Network:

• Medications: CHAMPVA beneficiaries can obtain their prescriptions through the Meds by Mail (MbM) program or from any pharmacy that accepts CHAMPVA.

• Meds by Mail (MbM): This program allows eligible beneficiaries to receive non-urgent maintenance medications delivered to their home at no cost. This is particularly useful for those who need ongoing treatment for chronic conditions.

• Retail Pharmacies: Beneficiaries can also fill prescriptions at retail pharmacies that accept CHAMPVA. They will need to present their CHAMPVA identification card.

Co-Payments and Cost Sharing:

• Cost Sharing: Beneficiaries may have to share the cost of prescriptions. Typically, CHAMPVA covers 75% of the allowable amount, and the beneficiary is responsible for the remaining 25%.

• Annual Out-of-Pocket Cap: There is a maximum out-of-pocket expense limit, which protects beneficiaries from excessive costs. Once the cap is reached, CHAMPVA will cover 100% of additional costs for covered services.

Processing Prescriptions:

• Meds by Mail: Beneficiaries should send their prescriptions to the MbM program using the provided order form. This program is ideal for long-term medications.

• Retail Pharmacies: Beneficiaries must present their CHAMPVA ID card and, if needed, any applicable co-payment. The pharmacy will bill CHAMPVA for the remaining amount.

Reimbursement for Out-of-Pocket Expenses:

• If a beneficiary pays out-of-pocket for a prescription at a pharmacy that does not bill CHAMPVA directly, they can submit a claim for reimbursement. The claim should include the receipt and a completed CHAMPVA Claim Form (VA Form 10-7959a).

Important Tips

• Medication Coverage: Not all medications are covered under CHAMPVA. It’s important to check the CHAMPVA Formulary or contact CHAMPVA Customer Service for specific medication coverage information.

• Prior Authorization: Some medications may require prior authorization. This means the prescribing doctor must get approval from CHAMPVA before the medication is dispensed.

VA Prescription Coverage Eligibility: Frequently Asked Questions (FAQs)

How Do I Get the VA to Pay for Prescriptions?

The VA provides prescription benefits to veterans based on their service-connected disabilities, income level, and other criteria. Categories of veterans who qualify for free VA prescriptions include veterans with service-connected disabilities rated at 50% or higher, low-income veterans who meet specific income thresholds, former Prisoners of War (POWs), veterans determined by the VA to have a catastrophic disability, veterans receiving Aid and Attendance or Housebound benefits, veterans receiving a VA pension, and veterans with special eligibility, such as those diagnosed with ALS (Lou Gehrig’s disease).

Are there co-payments for VA prescriptions?

Yes, while many veterans qualify for free prescriptions, others may need to make co-payments. Co-payment requirements depend on the veteran’s priority group and the type of medication. Veterans in Priority Group 1 do not pay any co-payments for medications, while those in Priority Groups 2-8 may have to pay co-payments for non-service-connected conditions and over-the-counter medications.

What is the VA Medication Copay Tier List?

The VA medication co-payment structure is divided into three tiers. Tier 0 has no cost for any supply. Tier 1, which includes preferred generic medications, costs $5 for a 1-30 day supply, $10 for a 31-60 day supply, and $15 for a 61-90 day supply. Tier 2, covering non-preferred generic medications and some over-the-counter medications, costs $8 for a 1-30 day supply, $16 for a 31-60 day supply, and $24 for a 61-90 day supply. Tier 3, which includes brand name medications, costs $11 for a 1-30 day supply, $22 for a 31-60 day supply, and $33 for a 61-90 day supply. Check the most current VA copay rates here.

What is the annual co-pay cap for VA medications?

The annual co-pay cap for VA medications is $700. Once a veteran has paid $700 in medication copays within a calendar year (January 1 to December 31), they will not have to pay any additional copays for the rest of that year.

Can I get free VA prescriptions filled at Walgreens?

Yes, veterans can fill their VA prescriptions at Walgreens through the VA-Walgreens partnership program. Veterans need to ensure they are enrolled in VA healthcare and provide their VA prescription details to the Walgreens pharmacist. Walgreens will process the prescription through the VA, and eligible medications will be covered. Co-payments may still apply based on VA eligibility and income category.

Can I get free VA prescriptions filled at CVS?

No, CVS is not on the VA’s free prescription provider list. Veterans attempting to fill a VA prescription at CVS will likely have to pay out of pocket unless they qualify under another government program like Tricare, which includes CVS as a network pharmacy.

Are over-the-counter medications covered by VA?

Over-the-counter medications are covered by the VA but may require co-payments unless they are prescribed for service-connected conditions. Veterans can choose to buy over-the-counter medications on their own to avoid co-payments.

How do I find in-network retail pharmacies for urgent care prescriptions?

Veterans can use the VA Facility Locator tool to find participating, in-network retail pharmacies for urgent care prescriptions. For assistance, veterans can contact the third-party administrator managing their region (Optum for Regions 1-3 and TriWest for Regions 4-5).

What should I do if I need urgent medications?

Urgent care prescriptions can be sent to an in-network retail pharmacy or VA pharmacy. Ensure the medication is on the VA Urgent/Emergent Formulary. Up to a 14-day supply with no refills may be authorized. If more than a 14-day supply is needed, the prescription must be sent to the referring VA medical facility pharmacy.

How are prescription costs determined for VA medications?

Prescription costs are determined by the tier of the medication (Tier 0, Tier 1, Tier 2, or Tier 3) and the supply amount (days of medication provided). Co-payments vary based on these factors and the veteran’s priority group.

Can veterans use drug samples or coupons?

No, the use of drug samples or drug coupons is prohibited for VA prescriptions. All medications must be prescribed and filled through the appropriate VA or in-network pharmacy channels.

What information is needed for electronic prescriptions to VA pharmacies?

The Department of Veterans Affairs (VA) accepts electronic prescriptions from community providers for all eligible veteran medications, including controlled substances. The published name of the VA pharmacy should be used for e-prescribing, typically formatted as “Town Name VAMC Pharmacy.” If electronic submission is not possible, fax and hard copy prescriptions are accepted.

How can veterans find their preferred in-network pharmacy for adult immunizations?

Veterans should ask their community provider to send a prescription for the vaccine directly to an in-network retail pharmacy for administration. They can use the VA Locator to confirm the pharmacy is in-network and check if the medication is on the Urgent/Emergent Formulary using the VA Formulary Advisor tool.

Are there any special programs for veterans with specific conditions like ALS?

Yes, certain conditions, such as ALS (Lou Gehrig’s disease), provide automatic eligibility for free prescriptions. Veterans with these conditions do not need to meet additional criteria to receive free medications.

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