Outpatient Prescription Drug Coverage Comparison

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The difference in prescription drug coverage betweeen MEDICARE, VA, CHAMPVA and Tricare

 

  Medicare Prescription Drug Coverage (Part D) VA CHAMPVA Tricare
Who is eligible? All people with Medicare. All veterans who are eligible for, and enroll in VA health care coverage. Spouse, survivor, or child of certain veterans killed or disabled in the line of duty.  Available to active duty and retired military and dependents. If age 65 or older an individual must have medicare Part B coverage to use the TRICARE pharmacy program. 
Who fills prescriptions Generally, prescriptions are filled at a plan participating pharmacy. Some plans may also offer a mail order option. Prescriptions are written by VA doctors or VA authorized civilian doctors. They may be filled at VA or civilian pharmacies or by mail Prescriptions may be filled at retail pharmacies or by mail Prescriptions may be filled at military treatment facilities, through the TRICARE Mail Order Pharmacy, at TRICARE retail network pharmacies, or at non-network pharmacies.
How much are premiums? $34 monthly national average for the premium (varies by plan) None None None
How much are copayments? (Note: Amounts may vary by plan.) $400 deductible, then 25% copayments until $3,700 total in drug spending. 100% payment until the $4,425 out-of-pocket limit is met. 5% or the copayment ($3.80 or $8.25), whichever is higher, after the $7,425 out-of-pocket limit is met and for the rest of the calendar year. $8 copayment for each 30-day or less supply of medication. VA limits drug copayments at $960 yearly for some veterans. $50 yearly deductible for all outpatient care, including retail pharmacy. Cost-share for retail pharmacy is 25% of the allowable amount. If no other drug benefits, may use Meds by Mail for maintenance prescription drugs. Once an individual meets the CHAMPVA catastrophic yearly out-of-pocket limit of $3,000 CHAMPVA pays 100% of prescription drug coverage. Military Treatment Facilities: up to a 90-day supply (formulary drugs only) at no cost. TRICARE retail network pharmacies: up to a 30day supply; $10 generic, $24 brand name, and $50 non-formulary copayment. TRICARE mail order pharmacy: up to a 90-day supply: free generic, $20 brand name, and $49 non-formulary copayment. Non-network pharmacies have higher cost shares and a deductible. TRICARE Prime enrollees pay point-ofservice charges which don't count toward the $3,000 out-of-pocket medical expense cap. An individual won't pay more than $3,000 in out-of-pocket expenses per fiscal year for ALL covered medical care and prescriptions.
Is help available for drug costs? Yes. Yes.  No.  No.
What drugs are covered (formulary)? Each Medicare drug plan has its own list of covered drugs (with certain requirements set by Medicare). National formulary of covered drugs. National formulary of covered drugs. CHAMPVA uses the VA formulary for prescriptions filled through Meds by Mail. Note: People enrolled in a Medicare drug plan won't be eligible for Meds by Mail. National formulary of covered drugs. Department of Defense policy requires a generic, if available. Note: People enrolled in a Medicare drug plan won't be able to use the TRICARE Mail Order Pharmacy benefit unless a TRICARE-covered item isn't covered by Medicare or the person is in the coverage gap.
Who is the "primary" and the "secondary" payer? Generally, a Medicare drug plan is the secondary payer if there is other prescription drug coverage. VA is the primary payer if it is a benefit or service provided or directed by VA. VA won't bill Medicare for prescription drugs prescribed by VA doctors. If a prescription is filled by a Medicare drug plan, it won't go to VA for any additional payment. Medicare is the primary payer and CHAMPVA is the secondary payer if it is a benefit payable by both Medicare and CHAMPVA. CHAMPVA will pay Medicare drug plan copayments up to 75% of the CHAMPVA allowable amount for prescriptions. Medicare is the primary payer if the individual is enrolled in a Medicare drug plan. Other health insurance is secondary payer if enrolled in a Medicare drug plan. TRICARE is the secondary payer if the drug is both a Medicare and TRICARE covered drug, if there is no other prescription drug coverage. TRICARE, as secondary payer, will pay the individuals out-of-pocket expenses (deductible and cost-shares) for TRICARE-covered prescriptions. TRICARE won't reimburse people with Medicare for their monthly Medicare drug plan premiums. People with Medicare will have no copayments for TRICARE-covered prescriptions until the Medicare coverage limit in total drug costs is reached. After the coverage limit, TRICARE becomes the primary payer and the person with Medicare is responsible for TRICARE pharmacy copayments/ cost-shares.

See our page that compares Medicare Part D and TRICARE for more details.

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