Community Care

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 are able to use MbM for nonurgent, maintenance medications. Prescribed, maintenance medication will be mailed to your home.*
*Refrigerated medications cannot be delivered to a post office box or outside of the continental United States.

You can use your local pharmacy in the OptumRx network for other prescription medications. 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 for the remaining amount.

If you have other health insurance with pharmacy coverage, including Medicare Part D, even though it is primary to CHAMPVA, you are still able to use an OptumRx pharmacy. Be sure to tell your pharmacy that you have both primary prescription coverage and CHAMPVA. In this case, you may not have a cost share if the medication is covered by your primary insurance as well as by CHAMPVA.

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 can 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.)

return to top

Using a Local Pharmacy

OptumRx 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 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 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

return to top

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.

Excluded Compound Ingredients

Excluded Medications

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

return to top