Currently frozen through the end of this year, VA medication copay amounts may be changing in January 2017, according to a Jan. 5, 2016 notice published in the Federal Register.
Non-exempt Veterans are now charged either an $8 (Priority Categories 2 through 6) or $9 (Priority Categories 7 and 8) copay for each 30 days or less supply of medication provided by the VA on an outpatient basis.
Under current regulations, a calculation using the prescription drug component of the Medical Consumer Price Index (CPI-P) determines VA medication copay amounts in future years. This formula has been found to create higher copayments than found in larger, non-VA retail pharmacies. The VA has attempted to remain competitive through copay freezes since 2009.
If amended, the VA regulations would replace the current formula used to calculate future increases with fixed-cost categories, or tiers, for medications. VA medication copay, effective January 1, 2017, would be:
| Type | Cost / Copay | Supply |
|---|---|---|
| Tier 1 | $5 | 30 days or less supply |
| Tier 2 | $8 | 30 days or less supply |
| Tier 3 | $11 | 30 days or less supply |
The VA would periodically decide which medications are to be included in each of the three Tiers. Veterans should be aware that the medications listed within each Tier can be changed “not less than once per year”; Tier 1 medications must meet seven exclusionary criteria. These criteria are intended to limit medications entitled to the lowest copay amount to those medications used long-term by a large number of Veterans. The VA will publish an annual (or more frequent) list of Tier 1 medications in the Federal Register and on the VA’s website at www.va.gov/health.
Federal law and regulation governs copay amounts — the minimum copay is $2, and the VA is prohibited from charging a Veteran more than the VA’s cost of the medication. The VA anticipates most Veterans will experience lower out-of-pocket costs for medications, a possible incentive for Veterans to take their medications as prescribed. The change is also intended to encourage Veterans to use one VA pharmacy to fill their prescriptions, avoiding potential risk of fragmented care that can occur when multiple pharmacies (VA and civilian) are used.
In addition to the establishment of the medication Tiers, the VA is proposing to establish a fixed copay cap of $700 in a calendar year for all Veterans enrolled in VA healthcare, including those Veterans in Priority Groups 7 & 8. Under current regulations, the cap would be $960 or more.
Review the full explanation and the proposed regulation changes at https://federalregister.gov/a/2015-33052. Comments can be submitted through www.regulations.gov in response to “RIN 2900-AP35-Copayments for Medications Beginning January 1, 2017.” Comments are due on or before March 7, 2016.
References: 38 USC 1722 A(a) and 38 CFR 17.110(b)(1)