Prescriptions
As an enrolled patient in the VA health care system, you can obtain medications and medical
supplies that are prescribed by your VA provider. Medications are prescribed from an approved
list of medications called a
formulary.
There is a co-payment for medications used to treat nonservice-connected conditions.
Medicare Prescription Drug Benefit & VA Health Care
As of January 1, 2006, the Medicare prescription drug coverage
(Medicare Part D) became available to everyone with
Medicare Part A or B coverage. Medicare prescription drug
plans provide insurance coverage for prescription drugs.
These plans will be offered by insurance companies and other
private companies. Plans will cover both generic and brandname
prescription drugs. The Medicare prescription drug
coverage is wholly voluntary on the part of the participant.
Veterans may choose to have both VA prescription coverage
and Medicare prescription drug coverage. Please note that
VA health care enrollment (which includes prescription coverage)
and the Medicare prescription drug coverage are separate
and distinct programs.
For veterans considering enrollment in a Medicare prescription
drug plan, there are several factors to consider such as
access and cost:
Unlike Medicare, which offers the same benefits for all
enrollees, VA priority levels may change and veterans may
not always have access to VA health care. Veterans may
benefit from Medicare drug coverage if they reside in or move
into a community living center or live in a geographical area that may
limit their ability to access their VA prescription benefits.
VA prescriptions, with limited exceptions, must be written by
a VA practitioner and filled through a VA pharmacy either in
person or by mail through VA’s Consolidated Mail Outpatient
Pharmacy Program (CMOP). Veterans may consider the
flexibility offered by a Medicare prescription drug plan to
get prescriptions filled from their local retail pharmacies.
Medicare requires that prescription drug plans contract with
pharmacies in your area.
A veteran who is or who becomes a patient or inmate in an
institution of another government agency (for example, a
state veteran’s home, a state mental institution, a jail, or a
corrections facility), may not have creditable coverage from
VA while in that institution.
If veterans want to wait and join a Medicare prescription
drug plan after May 15, 2006, and are enrolled in the VA
health care system, they won’t have to pay a higher monthly
premium for joining a Medicare drug plan later.
All Medicare prescription drug plans will provide at least
a standard level of coverage set by Medicare. Some plans
might also offer more coverage for a higher monthly premium.
VA has determined that its prescription drug coverage
for veterans enrolled in the VA health care program is
at least as good as the standard Medicare prescription drug
coverage benefit, meaning that enrollment in VA health care
provides veterans with “creditable coverage” for Medicare
Part D purposes.
This means that enrollment in the VA health care system
provides a prescription drug benefit that is at least as good
as the Medicare drug coverage. Veterans enrolled in the VA
health care program may choose not to enroll in a Medicare
prescription drug plan, if they feel the VA program meets
their needs. If veterans wish to enroll in a Medicare prescription
drug plan at a later date, they will not be subject to the
late enrollment penalty.
Dental Care
In general, dental benefits are limited to:
- Veterans who have service-connected dental conditions
- Former prisoners of war (POW)
- Veterans who are rated by the VA for service-connected conditions and are permanently and
totally disabled
Contact your local Veterans Service Center to determine whether you are eligible for dental benefits.
Chiropractic Care
If you are enrolled in VA health care you are eligible for chiropractic treatment. Discuss the
need for chiropractic care with your VA primary care provider. You may be required to see a VA
specialist before seeing a chiropractor.
Non-VA Care
In limited circumstances, VA may authorize payment for health care services outside a VA Medical Center. Payment for
care outside VA is governed by strict federal regulations; service-connected disability rating is the basic criteria for most
authorized care outside a VA facility.
Most non-VA care must be authorized in advance. If the care you require is not available within the VA system, your VA
primary care provider may refer you to services outside VA. If non-VA care is pre-authorized, you will receive a letter
stating the exact services authorized at VA expense and the specific timeframe the authorization is valid. Care rendered
beyond the authorized services and timeframe is the veteran’s financial responsibility. If you are required to make copayments
for VA care, the same co-payments will apply for non-VA care.
In emergent situations, VA may consider payment of non-VA outpatient and inpatient care that has not been pre-authorized.
Contact the Network 2 Fee Processing Center at 1-800-396-7929 for more information.
We encourage you to seek care at our VA facilities, but never place yourself at risk in an effort to avoid incurring a medical
bill! The Millennium Health Care and Benefits Act was enacted to provide a safety net for veterans enrolled in VA Health
Care who have no other means of paying a non-VA hospital bill for emergency services.
Payment decisions are based upon eligibility criteria, medical necessity, and availability of the service within the VA Health
Care system. A veteran may always submit a claim for payment consideration. The following guidelines will assist you:
| If The Care Is: |
And The Service Is: |
Submit Claim Within: |
| Preauthorized |
Inpatient or Outpatient charges |
30 days of outpatient care or patient discharge from inpatient care |
| Not Preauthorized |
Emergency Medical/Outpatient or Inpatient for Service-connected disability |
As soon as possible but no later than 2 years from the date of service |
| Not Preauthorized Millennium Bill |
Emergency Medical/Outpatient or Inpatient for non-service connected condition |
90 days from determination of no other health care payer. Veteran is solely responsible for costs of health care; may submit to VA for payment consideration |
How to File a Claim for Non-VA Provided Care
VA requires the following information on all claims submitted for payment for medical services provided to you:
- Full name (include middle initial)
- Full address (include zip code)
- Social Security Number
- Full name of provider
- Completed CMS 1500 and /or UB-92 billing forms
- Any other health insurance information
- Receipt (cash, check, or credit card) clearly acknowledging payment made for specific medical care and services
Claims for payments for your health care should be submitted to the Fee Department of the VA facility that authorized
payment of care in advance. If you are not sure if VA authorized payment of care in advance, you may submit health care
claims to the nearest VA Medical Center Fee Department.
All fee dental care must be authorized in advance.
All claims for care delivered OUTSIDE the United States (except the Philippines) are sent to:
VA Health Administration Center
Foreign Medical Program
PO Box 65032
Denver, CO 80206-9021
Or phone (303) 331-7590 for further guidance.
Filing Information for Claims Not Pre-Authorized
All health care claims considered for services not pre-authorized by VA will require additional information (claims for
treatment of medical emergencies when you were not able to obtain treatment at VA facilities):
- VA Form 10-583 with information in Part 1 Blocks, 1, 2, 3, 4, and 5 completed
- You can obtain VA Form 10-583 and additional information from the Fee Department at any VA Medical Center
- Claims considered for payment under the Millennium Bill, “payer of last resort” require certification by the claimant
that no other health care payer exists for the specific clams being filed
Claims Requiring Medical Documentation
Other medical documents may be required by the local VA facility to consider payment. Your local VA Medical Center Fee
Department will assist you in retrieving the appropriate documentation.
Filing Deadlines
VA Fee Basis programs have different claims filing deadlines depending on how the claim is being considered for payment.
The table on page 17 shows the timelines for those programs.
Please contact the Fee Department for additional information and assistance in filing claims for your health care services:
400 Fort Hill Avenue/FPC
Canandaigua, NY 14424-1188
1-800-396-7929
Long Term Care Co-Payments
Some veterans without service-related medical problems will be charged co-payments for extended care. The
co-payments are tailored to the individual and based on the veteran’s ability to pay. The Millennium Health
Care and Benefits Act mandated this change.
Veterans who are not required to make extended care co-payments include those:
- with any compensable service-connected disability
- whose incomes are below the VA single pension level of $9,556
- who have received extended care from VA continually since November 1999
Under the new regulations, veterans receive the first 21 days of care free in any
12-month period. After that, the maximum that veterans could pay is:
- $97 for each day of community living center care
- $15 for each day of adult day health care
- $5 for each day of domiciliary care
- $97 for each day of institutional respite care
- $15 for each day of non-institutional respite care
- $97 for each day of institutional geriatric evaluation
- $15 for each day of non-institutional geriatric evaluation
Travel
Reimbursement for mileage or public transportation may be paid for the following:
- Veterans with service connected disabilities rated at 30% or more
- Veterans traveling for treatment of a service connected condition
- Veterans receiving a VA pension
- Veterans traveling for scheduled compensation and pension examinations
- Veterans whose income does not exceed the maximum VA pension rate
Mileage reimbursement is made at the rate of $.11 per mile. Travel payment is subject to a $3.00 deductible
for each one-way trip. There is an $18 per month maximum deductible. If you are traveling for a
compensation and pension examination, you are not subject to a deductible.
Special Mode Travel
If you have a medical condition that requires a special mode of transportation and are unable to pay the cost of that transportation,
VA may cover the cost. Special modes of transportation costs must be pre-authorized by VA. If you have a medical
emergency, and a delay in travel would be unsafe, travel does not need to be pre-authorized. When traveling by special modes
of transportation (ambulance or specially equipped van), there is no deductible.
Special Registry Programs
VA has established a special registry designed to provide you with examinations/medical care, if you have been
exposed to one of the following:
- Agent Orange or other herbicides
- Ionizing radiation
- Environmental contaminants associated with service in the Gulf War
Contact the nearest VA health care facility if any of these apply to you.
Spinal Cord Injury (SCI)
VA provides a full range of care for veterans who have:
- Sustained injury to the spinal cord
- Multiple Sclerosis
- Other non-progressive neurological deficit lesions
The VA has many Spinal Cord Injury Centers. Contact the nearest VA
health care facility for more information.
Blind Benefits
Services for blind veterans are available at all VA medical centers. To determine your eligibility for blind rehab center/
clinic services, contact the Visual Impairment Services (VIST) Coordinator.
Former Prisoner of War (POW)
Former prisoners of war are placed on a special list and may be eligible for certain health and dental benefits, as well as
special medical exams. If you are a former POW, please contact the Veterans Service Center for more information.
General Exclusions
VA Health Care does not cover:
- Abortions and abortion counseling
- Contraceptives not requiring physician’s prescriptions such as condoms, spermicidal foams, and jelly
- Cosmetic surgery except where determined by VA to be medically necessary for reconstructive or psychiatric care
- Drugs, biologicals, and medical devices not approved by the U.S. Food and Drug Administration
- Gender alteration
- Health club or spa membership, even for rehabilitation
- Infertility services, such as artificial insemination, in vitro fertilization, or embryo transfer, unless related to a
service-connected condition
- Reproductive sterilization/reversal of sterilization (except when determined to be medically necessary)
- Services not ordered and provided by licensed/accredited professional staff
- Special private duty nursing
