CHAMPVA Pharmacy Benefits, Meds by Mail and SXC Health Solutions

CHAMPVA helps pay for more than just regular doctor visits, inpatient and outpatient or emergency care.  It also shares in pharmacy costs that meet the VA Health Administration Center’s criteria for coverage.  You have two types of CHAMPVA pharmacy benefits: low-cost medicine at local pharmacies, and FREE non-urgent medication via the Meds by Mail program.

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SXC Health Solutions

SXC Health Solutions Inc.handles electronic claims for pharmacies. If you use a local pharmacy that is part of the SXC network, you pay only your CHAMPVA cost share, which is 25%.  SXC will then electronically bill CHAMPVA for the remaining 75% of the cost of your medicine.   This is, of course, after you have met your yearly CHAMPVA deductible.

Besides the money it saves you, using an SXC pharmacy also saves you the trouble of having to file a CHAMPVA claim yourself.  The pharmacy takes care of that.

Eligibility for SXC

You are eligible for SXC if:

  • You are a CHAMPVA beneficiary
  • You have no other health insurance (OHI) with pharmacy benefits that pays before CHAMPVA, e.g. Medicare Part D

According to the CHAMPVA SXC fact sheet, if you have OHI that pays for pharmacy before CHAMPVA does, you cannot use SXC.  However if your OHI is a CHAMPVA supplement that pays after CHAMPVA, you can still use SXC.

For Non-SXC Pharmacies

If you do not find an SXC-member pharmacy in your area, you can still use a non-network pharmacy.  In that case, you pay the full amount upfront.  Later you can file a claim for reimbursement using VA Form 10-7959a.  CHAMPVA will pay you back its allowable amount.

Also you will have to use a non-SXC pharmacy if you are ineligible for SXC due to having OHI that pays before CHAMPVA does. If you have OHI primary to CHAMPVA, the OHI pays for your pharmacy first, and CHAMPVA second.

If you have Medicare Part D, you still get CHAMPVA pharmacy benefits, but you can’t use SXC.  See Medicare Drug Plan fact sheet and next section.

Medicare Part D

If you are enrolled in Medicare Part D, Prescription Drug Plan, you cannot use either SXC or Meds by Mail.  You still are eligible for CHAMPVA pharmacy benefits, but CHAMPVA will be the secondary payer to Medicare, which will be the primary.

CHAMPVA Pharmacy Card

If you are eligible for this type of pharmacy benefit, you should have received a pharmacy identification card similar to your CHAMPVA ID card.  If you do not have one, and you know you are eligible because you have no other health insurance with pharmacy benefits, contact SXC Health Solutions.

Meds by Mail

This is a drug-mailing service for CHAMPVA beneficiaries.  You can have non-urgent, maintenance medication sent to your home for FREE.  Examples of drugs covered are blood pressure medicine, insulin and chronic pain medicine.

To learn more about Meds by Mail, see the official brochure.

Eligibility for Meds by Mail

You are eligible for the Meds by Mail program if:

  • You are a CHAMPVA beneficiary
  • You have no other health insurance that has pharmacy coverage, e.g. Medicare Part D

If you have Medicare Part D and prefer to use Meds by Mail, please do not cancel Part D until you have first contacted CHAMPVA and asked for a “letter of creditable coverage” to be sent to Medicare.

Generic Drugs and Brand Names

The VA prefers to supply generic drugs.  If you are prescribed a brand-name medicine, CHAMPVA will attempt to supply its generic equivalent. If you must have the brand name specified, you must contact Meds by Mail first.

 

 

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