CHAMPVA Pharmacy Benefits: List of Covered and Non-Covered Drugs

CHAMPVA offers good pharmacy coverage to its beneficiaries.  Through the program, you can get prescription medicine at a discounted rate, or even for free if you use its mailing service.  However there are conditions and limitations to these benefits.  Your physician can recommend drugs for either labeled indications or “off-label use” provided that requirements are met.

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Coverage of Label Indications

Label indications are the uses of a drug as indicated in its label (such as a bottle or box and the instructions that go with it).

  1. The drug must be FDA-approved (FDA = Food and Drug Administration)
  2. The drug must be prescribed by a provider such as a physician
  3. All applicable state laws are observed in the issuance of the drug

Coverage of Off-Label Use / Indications

Sometimes a physician may prescribe a drug for a purpose other than its indicated use on the label.  This is referred to as “off-label use” or “off-label indications.”   An example may be a prescription to use cough syrup to help a patient fall asleep at night.

CHAMPVA will cover off-label use only if there is compelling evidence to support it.  The evidence must show that it is safe and effective to use.  Further, said off-label use must be accepted as standard in the medical community.

Examples of evidence are controlled clinical studies, and published reports made by authoritative organizations such as the American Heart Association (AHA) or the American Cancer Society.

If these conditions are not met, the prescription for off-label use will not be covered.

Non-Covered Medicine

Examples of non-covered medication are:

  • Drugs prescribed by an immediate family member of the beneficiary, or one who lives in the same house as the beneficiary or the CHAMPVA sponsor
  • Drugs prescribed in connection with cosmetic treatments that are not medically necessary
  • Weight control pills and similar drugs, such as drugs for non-surgical treatment of obesity
  • Over-the-counter contraceptive medicine
  • All over-the-counter drugs and medicine, except for insulin and related diabetic supplies
  • Nicotine patches and other quit-smoking material
  • All drugs that are not FDA-approved

Pharmacy Mailing Program

CHAMPVA provides a no-cost drug refill mailing service called Meds by Mail.  You can order your non-urgent maintenance medicine, such as for blood pressure, through this service for free.  All CHAMPVA beneficiaries who do not have other health insurance that provides pharmacy benefits may use MbM.

Network Pharmacy Benefit

As a CHAMPVA beneficiary, you can buy your prescription drugs at a discounted rate if you use an SXC Health Solutions Inc. partner pharmacy.  When you use such a pharmacy, you pay only your cost share of the CHAMPVA allowable amount for your purchase.  You don’t pay the full price for the drug, and you don’t need to file claims.

Prescription Limitations

Prescription is limited to:

  1. No more than 12 months’ supply total (prescription + refills)
  2. No more than 90 days’ supply per refill

Overseas Medication

If you order your prescription medicine from abroad, they are still subject to the same standards as locally purchased drugs.

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