Veterans Choice Program Eases Process Somewhat for Outside Prescriptions

By Annette M. Boyle

The VA has developed guidelines for how patients using the Veterans Choice Program can fill prescriptions. This photo shows the pharmacy at the Long Beach, CA, VAMC.

The VA has developed guidelines for how patients using the Veterans Choice Program can fill prescriptions. This photo shows the pharmacy at the Long Beach, CA, VAMC.

WASHINGTON — Veterans who receive care through the Veterans Choice Program may not have many choices when it comes to prescriptions from those outside providers, but they do have more than those who receive prescriptions from non-VA providers through other programs.

Veterans usually are required to visit a VA provider to get a prescription that can be filled and subsidized by the VA. Under other community-care programs, veterans who receive treatment elsewhere still need to have a VA provider verify that the prescription is medically necessary and appropriate.

In its Interim Final Rule, the VA provided veterans eligible for the Choice program a special exemption from this validation requirement. The department recognized that “imposing such a requirement on veterans eligible under the program would not make sense, because their eligibility is predicated on either being unable to be seen within a timely manner or because of difficulties they face in traveling to a VA medical facility.”

The VA will fill and pay for most prescriptions written by Choice providers, including prescriptions for drugs, over-the-counter medications and medical and surgical supplies. The non-VA provider can mail or fax the prescription to a VA facility, along with the episode of care authorization form, and the VA will mail the prescription back to the patient, substantially reducing the process for veterans who can wait a few days to receive their prescriptions.

The process requires providers to submit their name, address, personal (not facility) DEA number, phone, fax, National Provider Identifier number, Social Security number, date of birth and, for providers contracted by Health Net, gender, in addition to the authorization and prescription information.

“There are more-restrictive limitations for controlled substances, as prescriptions may not be faxed and, for Schedule III-V drugs, they must contain the provider’s hand-written signature,” said Constance Wilkinson, a member of the Washington law firm Epstein Becker Green. “This may keep the barriers high for many patients with mental health issues.”

Patients can take a hard copy of the prescription and the episode-of-care authorization form to the VA medical facility or, for urgent situations, to a local non-VA pharmacy. The VA limits prescriptions filled at outside pharmacies to a 14-day supply with no refills, and veterans must pay upfront for them. They then can submit a request for reimbursement to the VA. If providers expect urgent medications to be continued beyond 14 days, they are advised to write a second prescription for the remainder of the quantity and submit it to the VA pharmacy for processing.

Overall, veterans have appreciated the change in policy. “Feedback from veterans shows that receiving non-VA care through the Veterans Choice Program streamlines the prescription process,” noted the Veterans of Foreign Wars’ Report on the Choice program.

The Choice plan does not remove all the usual restrictions, however. “One of the most significant gating issues is the requirement that the drugs prescribed must be on the VA National Formulary; if not, medical necessity must be documented in a nonformulary request by the non-VA provider to the VA medical facility pharmacy staff before the prescription is submitted,” Wilkinson told U.S. Medicine.

For veterans and providers who fall in one of the three regions where Health Net serves as the third-party administrator of the Veterans Choice Program, urgent prescriptions filled at an outside pharmacy must conform to the National Formulary. In TriWest regions, providers are allowed to write prescriptions for 14 days of an urgently or emergently needed medication to be filled at an outside pharmacy but must complete the Formulary Request Review Form to the VA for consideration for any additional days of the medication.

While the change in the prescription-review policy eliminates the need for veterans to see two providers for each prescription, it does not reduce the need for pharmacists’ oversight and consultation — it may increase it.

“If a prescription does not follow the VA National Formulary, a VA pharmacist will follow up with the prescribing provider to determine if the prescription can be rewritten for a prescription available on the VA National Formulary or if certain criteria is met in order to initiate a medically necessary nonformulary drug review. Nonformulary drug reviews are performed on a case-by-case basis,” according to the website of Health Net, one of two third-party administrators for the Choice program.

“While the Interim Final Rule does not alter how prescriptions are filled or reimbursed, given the expansion under the program, we anticipate that the number of prescriptions filled at the VA from non-VA providers may increase,” explained Wilkinson and her colleagues in a client alert on the subject.

Working with new providers to coordinate prescriptions with the VA National Formulary is likely to consume significant time, as few other healthcare systems or programs, including the DoD and Medicare, have such a restrictive formulary.

Efforts to broaden the formulary continue and may affect the options available to veterans through the Choice program as well as others, according to Wilkinson’s alert, which notes that “one of the legislative proposals still under consideration in the National Defense Authorization Act For Fiscal Year 2016 would require a joint-uniform formulary between the Department of Defense and the Department of Veterans Affairs to permit transitioning veterans to continue their medications, with a particular concern for psychiatric conditions, sleep disorders and pain management. If this ends up in the law, it could be one incremental step toward expansion of the VA National Formulary.”

Comments (15)

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  1. Anissa Litwin says:

    I don’t understand how this article explains the differences in the Choice Program that have made the non-VA prescription process easier. I work at a VA pharmacy and this is the same process we had when the Choice Program first came out. Also, I don’t agree with the comment from the Veteran of Foreign Wars Report that the process is streamlined. I’ve run into issues where a non-VA provider does not write a prescription for a 14 day supply of medication and another prescription for the maintenance med. I’ve run into issue where the vet didn’t know the authorization number was required. Also issues where the vet could not afford a 14 day supply and another issue where the vet did not trust that he would be reimbursed for a med if he did pay for it. I had a vet from another VA ask if he could get is non-VA prescriptions filled at my VA because it was closer to the non-VA providers office. But we could not process those prescriptions because he had to take them back to his VA but it was a weekend and he wasn’t sure if they could do it. I think the Veteran’s Choice Program is a good idea but more work needs to be done to make the prescription process better.

    • Don England says:

      I see an outside specialty doctor. Nothing I take is on the VA formulary, yet when outside provider gives a change in meds, VA second guesses it. Right now with my recent change of med, VA second guess process has lasted 21 days.

  2. Charlie says:

    The change is really a non change. That aside, what really needs to be done is to simplify the overall outside provider prescription process. Specialist care for veterans located farther than 40 miles from is still a problem. Physicians that were willing to work with “Fee Paid” are often not willing to deal with the current “Choice Program” due to is ongoing problems.
    As it currently stands, the choice program adds another level of complexity,delay, and cost, compared to using community medical services in a more normal manner.
    It makes sense to provide long term prescriptions via the VA, but obtaining prescriptions needed to treat emerging conditions is a problem for many veterans in terms of cost and timely availability. In short, there is no real reason why a veteran should not be able to obtain drugs/prescriptions as he/she would under Medicare, with the co-pay and out of pockets paid by the VA. This has been a long standing complaint of veterans, and the VA has deliberately FAILED to meet the obvious needs in this area. Instead, it historically has left veterans on their own to obtain prescriptions needed to start prompt treatment.

  3. Bruce says:

    I just got payment denial of $500 for med on my TKR in August 2015. I was in the Choice Program. I could not get the VA Pharmacy in Durham NC to fill my prescriptions before surgery. I paid for them self and sent all the paper work to Salem Va for reimbursement. Well 4 mounts later I get a letter saying that the Pharmacy in Durham NC is refusing my payment stating not authorized. This is mess. I have sent in copies from the Choice Program authorizing everything. They just do not want to pay so kiss $500 by by..

  4. Billy Whisenant says:

    Where do I submit receipts for out of pocket medication costs that the choice program would not pay for ? Turns out the choice program is their choice and not the veterans. I am using the skills the marines taught me for fighting to fight this program and will stay with it till they do what the say they are honored to do for us veterans. This is an insult and a sham and difficult for us to deal with when we are ill and need support not run arounds and letters telling us how important we are as they avoid helping us and make it difficult to navigate a system it seems they don’t understand.
    Sure would appreciate a place to submit my legitimate claim for reimbursement.
    Thanks
    Semper Fi

    • Ken says:

      I had my first visit to a physician through the choice program yesterday and had my prescription filled at a non-VA pharmacy i.e. Walgreens. Today I spent several hours on the phone speaking with VA and Choice reps to find out how I submit my claim for reimbursement. I was finally given the number to the Fee Basis department in my area and was provided with instructions on the reimbursement process. All that needs to be done is first find the mailing address where the documents need to be sent (find the number for the fee basis team in your area)and send in the prescription info the pharmacist staples to the bag and a copy of the receipt. I was told it takes about a month to get the check.

  5. GLENN SMITH says:

    The “CHOICE PROGRAM” as a whole has worked out for me. I do receive much better care and attention by my Choice provider. My SC Injuries have never reexamined for current up to date condition(s) for approximately 20 years by the VA. My prescriptions are based on the same early on evaluations (dangerous quality care). No wonder vets are dying. The latest boondoggle I have encountered is the VA requiring me to have a VA Primary Care Provider to approve and review my CHOICE Primary Care Provider’s prescription orders. (The Choice Provider without a doubt is more qualified than the VA to prescribe medication). The VA Provider is protected by the Governments Blanket of no-blame/accountability. The Choice Provider is NOT. So “Why do I need the VA provider?” Just another way to ring in the expelled vets that went to the Choice program due to the VA’s incompetence to provide me with a VA Provider and Prescription medication fills/refills. If anyone wants this crap to continue Vote for the wrong party.

    • GLENN SMITH says:

      HELLO I HAVE RETURNED WITH AN UPDATE TO MY EARLIER POST. I STILL AM ATTEMPTING TO GET MY PRESCRIBED MEDICATIONS FILED BY THE VA. I AM ON THE “CHOICE” PROGRAM. THE CONTACT NUMBERS THAT I WAS FURNISHED BY BOTH TRIWEST, CHOICE PROVIDER AND THE VA TO HAVE A VA PCP ASSIGNED HAVE NOT WORKED, “THE PERSON IS NOT IN THE OFFICE RIGHT NOW PLEASE LEAVE A MESSAGE AND WE WILL GET BACK WITH YOU.” DOES THAT SOUND FAMILIAR VETS? ALL I KNOW IS THAT I PAY FOR MY MEDS AND USE MY “CHOICE” PROVIDER AS A CIVILIAN PCP. THIS IS WHAT IS KNOWN AS “TYPICAL GOVERNMENT” FIX WHAT IS BROKE AND BRAKE WHAT IS FIXED. THE VA NEEDS TO STOP JUSTIFYING THEIR MEANS AND FOCUS ON THEIR SERVICE TO VETS, THEY GET PAYED HIGH FIVE AND SIX DIGIT NUMBERS TO KEEP QUIET AND BECOME A PUPPET. FT IN PHOENIX.

  6. Jim king says:

    I can not find any info on who what where to send this request for reimbursement of non VA prescriptions. Thanks

  7. Donald Bennett says:

    Here I sit, in the Charles Wilso VA Outpatient parking lot in Lufkin, TX. It’s Friday at 4:35pm. I’ve already been 2 days without my pain meds, and now have to wait a other 2. I read that VA MIGHT reimburse a 14 day supply if I fill the prescription at a civil pharmacy. But, that’s not the way the law works in Texas. You can’t split what is written on your prescription. Only what is written can be filled. That is state law. So, I would like the genius that thought this moronic idea up to explain how can a federal agency make a dumb rule like this up? Especiay, when they don’t know the rules of each state. You can’t put all of us under an umbrella like that. The closest VA Hospital that can fill this is a 3 hr drive there, and then a 3 hour drive home. My local outpatient doesn’t open n Saturdays, and I need my medication. I dont have the $100 to fill it, because I can’t work after y’all broke me. So, what the fuck do we disabled vets do?

  8. Chloresse Wright says:

    I think many of the problems can be fixed if veterans are made aware of the rules when notified that they are to the VA choice provider. If veterans don’t know to ask the provider for 14 day prescriptions, they will accept a 30 day prescription.

    Also, the staff at the VA need to be made aware of the rules. I went in to my local VA and I spoke to 3 different people and received three different answer about getting pains med reimbursed after surgery. Only once I left the facility and sat in the parking lot, I called the Fee basis office and was told that YES my prescription would be reimbursed. If I had taken the word of 2 of the staff members I would have left with a $75 bill not being taken care of.

    My next situation came when my VA Choice Provider wanted me on an antibiotic for infection after the surgery. I took that prescription to the VA instead of paying for it, as I had previously done. Again a employee tried to tell me that the VA doesn’t do that. I turned in the the prescription on Wednesday and didn’t get it until Friday. Because it was for the an infection the pharmacist asked that it be over nighted to me, but because it was turned in after the 1pm cutoff time; it technically didn’t go in until Thursday. Instead of the $4 that Walmart charges for antibiotics, the VA paid for an over night delivery. Now we all know that an over night delivery costs more that $4. The VA is wasting money, when they could make this VA Choice system work for them and the veterans.

    Finally, I think the rules need to be changed. Educate the veterans, educate the staff and re work it all together. This system is suppose to help us veterans. Why could they not have a contract with Wal-Marts and other pharmacies like they used to. Stop trying to hid our benefits in paper work and leg work. We deserve better.

  9. Dustin Miller says:

    I am wondering if anyone can fill me in I started receiving treatment and meds from a community grant based program a few weeks after I moved to Wyoming ever since then I been back n forth with the local va outpatient clinic the nearest va hospital veterans choice liaison and the provider I was seeing I was sadly misinformed that all would be handled and my attention sought if needed and ever since then I been getting the same story at my doctors saying they weren’t able to bill or submit a claim so the continued with the grant program funding my scripts until this week they told me they were no longer going to be treating me nor refill my medication witch has severe physical symptoms when not taken plus mental anxiety and panic attacks these doctors knew this happens to me yet they simply denied me any further treatment for unjustified reasons now I can’t get the meds I need and risk losing my job n all I’ve worked for cause the people I talk to from veterans choice told me what I do and give the pcp so they can bill them but when they called the va they were denied being able to make those kind of arrangements now what can the provider just take me of meds I was approved for by veterans choice

  10. Robert Nowlin says:

    Well after reading all this and waiting for refund since May 2016. I guess I just forge about my piddly $205. Sure hope my Doctors get paid cause VA is ruining Veterans credit also.

  11. John Haluska says:

    After years of having medical coverage at work , I retired applied for VA Medical coverage and was put into the Choice Program. After too much red tape decided to stay with Medicare instead and paid out of pocket for prescriptions Part D.As the costs for my Meds started to rise to the point it was too expensive I went to the VA using the choice program to get my Meds . I get all my meds filled at the VA sent by mail. I have service related health conditions which is the reason for the VA COVERAGE. I tried to add 2 skin creams to the Meds I use and was told I don’t qualify because I am no longer in the Choice program news to me . Choice told me I was covered Va tells me Iam not . I will visit my VA service officer on Tue of next week to find out who is correct. People who say the VA is getting better , I say better at what?

  12. Kelly Williams says:

    Recent back surgery covered through TriWest at a non-VA facility has proven to be a pain in the butt when trying to have my prescriptions filled at WalMart. I received a prescription for 270 Percocet (1 month supply). Walmart discount price is 249.00. there is no way I can afford that having left my job to have surgery and frugal with every dime. VA will only provide reimbursement for a 14-day supply, which means I had to ask Walmart to only fill 14 days worth of the prescription (119.00), and I will have to go back to the spine institute, request that the prescribing nurse verify with Walmart that I only received 126 of the 270 pills, and request a new prescription for the remaining 144 pills, which I must then hand deliver to the VAMC, and wait for the script to be verified, and the remainder of my prescription to be mailed to me via USPS with mandatory signature upon delivery. A the closest VAMC with a pharmacy is 160 miles round trip, this makes for more than just a mere inconvenience. I suppose I should count my blessings as had the VA performed the surgery, I would have been sent home with Mortin and Tylenol for pain relief (as per their new stance on opiate dispensing). Truly sick & fed up with the VA.

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