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CHAMPVA and Medicare Part D

prescription drugs

If you are enrolled in the CHAMPVA program you may choose to participate in Medicare Part D.

If you have Medicare Part D, even though it is primary to CHAMPVA, you are still able to use a OptumRX pharmacy, but you will not be able to use Meds by Mail. Be sure to tell your local pharmacy that you have both Medicare Part D and CHAMPVA-CBOPC.

Pharmacies that are a part of the OptumRX network will collect your 25% cost share/co-pay along with the annual deductible and send the claim to CHAMPVA for the remaining amount. If you have other health insurance that is not Medicare Part D, you can submit a paper claim to CHAMPVA for the portion that is paid out of pocket. The OptumRX Retail Pharmacy Network is a pharmacy benefits manager that has contracted with CHAMPVA to electronically process pharmacy claims. There are over 82,000 pharmacies nationwide that participate in the OptumRX network.

What is the Medicare Part D Prescription Drug Plan?

The Medicare Prescription Drug Plan is a voluntary prescription drug plan that provides beneficiaries with assistance paying for prescription drugs. To participate, beneficiaries must enroll in one of the many hundreds of Part D plans offered by private companies. If you currently are enrolled in Medicare Part D, you should review your plan each year to ensure you have the plan that best works for you. The annual open enrollment period for Part D runs from October 15 – December 7. During this period, you can switch to a different Medicare Part D plan if your needs change.

Should I participate in the Medicare Part D Drug Plan?

Whether or not to participate is a personal decision. However, we would like to remind you that Medicare Part D is considered Other Health Insurance (OHI) and will be your primary prescription insurance. After the Medicare Part D plan is billed and you pay your copayments, CHAMPVA will reimburse your copayments up to 100% of the CHAMPVA allowable amount for prescriptions. You will then be responsible for any costs not covered by Medicare and CHAMPVA.

What are the cost differences between the Medicare Prescription Drug Coverage and CHAMPVA?

  Medicare Part D Primary CHAMPVA Primary
Cost to enroll (premiums) $384 per year (approx. for 2015) -0-
Catastrophic cap (Your maximum out-of-pocket expenses, excluding premiums) $4,700 per year (prescription costs only) and then the greater of $2.15 for generics, $5.35 for brand name drugs or 5% $3,000 per year: All covered prescription and medical expenses apply towards the catastrophic cap. Once $3,000 cat cap is met, CHAMPVA pays 100% of the allowable for all other covered prescription and medical expenses for the remainder of the calendar year.
Prescription Copay/ Deductible Dependent on Plan Retail: 25% copay, $100 Family/ $50 Individual Deductible Mailorder: Meds by Mail (MbM), No Copays and No Deductibles

What are the Medicare Prescription Drug Plan deductibles and copayments for the standard drug benefit and what will I pay?

Your Medicare deductibles and copayments for 2015 are estimated to be:

  • $250 deductible
  • 25% copay for prescription drugs for the first $2,250 in prescription drugs
  • 100% beneficiary responsibility for prescription drugs from $2,250 until their out-of-pocket costs reach $3,600
  • After $3600, they pay the greater of $2/$5 copay or 5% for rest of calendar year

Can I enroll in Medicare Part D and still have CHAMPVA coverage for prescriptions?

Yes. Keep in mind that you may have Medicare Part D enrollment costs. Medicare will be your primary prescription coverage and CHAMPVA will pay as secondary coverage.

If I am enrolled in the Medicare Part D, can I also participate in the CHAMPVA Meds by Mail Program?

No. Enrollment in the CHAMPVA Meds by Mail (MbM) is available only for those who do not have any other prescription drug coverage. If you currently use Meds by Mail which does not charge copays or deductibles and elect Medicare Part D, you will no longer be eligible for Meds by Mail and must obtain the prescriptions through the pharmacies authorized by the Medicare Part D plan you choose

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