No VHA Prescription Copayment Increase Seen In January

No VHA Prescription Copayment Increase Seen In January

Any VHA prescription copayment for treatment of a non-service connected disability or condition will not increase on January 1, 2017, the Department of Veterans Affairs (VA) has announced in the Federal Register.

Prescription copayments and the corresponding annual copayment cap will remain at the current rate for Veterans enrolled in Veterans Health Administration (VHA) health care Priority Groups 2 through 8 until February 26, 2017. VHA first extended this copayment “freeze” in 2010.

As a result, copayments for each 30-day or less supply of medication provided by the VA on an outpatient basis (excluding medication provided during treatment) will remain at these levels:

  • Priority Groups 2 – 6 $8           Annual [Calendar Year] Cap $960
  • Priority Groups 7 – 8 $9

The VA acknowledges that patients are willing to fill prescriptions “on the outside” rather than at the VA to save money. As a result and in an attempt to remain competitive and keep VA prescriptions filled “in-house,” the VA plans to implement a tiered copayment structure for “certain medications,” similar to the practice of other federal agencies and the commercial sector. Even so, the VA admits the new structure will “generally result in increased medication prices” for veterans. Furthermore, the VA may not require a veteran to pay an amount in excess of the VA’s cost of the medication.

The tiered copayment structure was originally proposed in the Federal Register in January 2016 yet have a planned effective date of January 2017. Most of all, with the VA unable to complete necessary system changes in a timely manner, the effective date for the new copayment structure has been moved to February 27, 2017.

Copayment Exemptions

Exemptions from copayment requirements include medications for:

  • A veteran with a service-connected disability rated 50% or more because of a service-connected disability or unemployability
  • A veteran’s service-connected disability
  • A veteran with very low income which does not exceed the maximum annual rate of a VA pension
  • Medication authorized under 38 USC 1710(e) to:
    • Vietnam-era herbicide-exposed veterans
    • Radiation-exposed veterans
    • Persian Gulf veterans
    • Post-Persian Gulf War combat-exposed veterans
    • Camp Lejeune veterans
  • Treatment of sexual trauma (authorized under 38 USC 1720D)
  • Treatment of cancer of the head or neck (authorized under 38 USC 1720E)
  • Provided as part of a VA approved research project (authorized under 38 USC 7303)
  • A former prisoner-of-war veteran
  • A veteran determined to be catastrophically disabled (per 38 CFR 17.36(e))
  • A vet receiving care for psychosis or other mental illness (per 38 CFR 17.109)

References

  • Eligibility for hospital, nursing home, and domiciliary care (38 USC 1710)
  • Counseling and treatment for sexual trauma (38 USC 1720D)
  • Nasopharyngeal radium irradiation (38 USC 1720E)
  • Copayment for medications (38 USC 1722A(b) )
  • Functions of the Veterans Health Administration: Research Programs (38 USC 7303)
  • Enrollment – Provision of hospital and outpatient care to veterans (38 CFR 17.36)
  • Presumptive eligibility for psychosis and mental illness other than psychosis (38 CFR 17.109)
  • Copayments for medication (38 CFR 17.110)

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