By Annette M. Boyle
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.”