Champva Copay

30-04-2021
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Medicare and ChampVA patients may be required to make a partial payment (e.g. Copayment, coinsurance or deductible) for a specific drug. The AKS statute prohibits a pharmaceutical company from offering or paying, directly or indirectly, any remuneration to induce Medicare or ChampVA patients to purchase a company’s drug. With CHAMPVA, the copay will be 25% for medications, this is included as part of your CHAMPVA coverage and the maximum out of pocket under CHAMPVA will be capped at $3,000 per year, lower than other private Part D plans which are $6,350 for 2020. When you buy your medicine at a participating pharmacy (that is, one that accepts CHAMPVA assignment) and you have no other health insurance with pharmacy benefits, you pay at a reduced rate as allowed by the VA. But you must also meet any unsatisfied deductible. The annual outpatient deductible is $50 per person and $100 per family under CHAMPVA.

  1. Champva Copays
  2. Does Champva Cover Part B Deductible
  3. Champva Copayment

Covered Services

Learn more about what we cover -
including health, dental, and pharmacy.

TRICARE covers diabetic supplies through the pharmacy and medical benefits.

Pharmacy Benefits

You can get the following diabetic supplies from a military pharmacy, through home delivery or at any TRICARE network pharmacy. Your prescription copayments will apply.

  • Insulin Products
  • Medicare does not cover insulin. TRICARE is the primary payer for insulin products.
  • FreeStyle Lite and Precision Xtra blood glucose strips
  • Blood and Urine Ketone/Acetone Test Strips
  • Diabetic Syringes and Needles Lancets

Medicare doesn't cover syringes. TRICARE is the primary payer for these diabetic supplies.

Medical Benefits

TRICARE covers the following diabetic supplies as durable medical equipment:

Copay
  • Home glucose monitors
  • Continuous glucose monitoring system (CGMS) devices approved by the Food and Drug Administration
    • With documentation by the physician of:
      • Poor diabetic control after six months of multiple daily insulin injections or insulin pump therapy
      • Blood glucose self-testing at least four times a day
      • Completion of a diabetic education program
  • Insulin infusion pumps for beneficiaries with:
    • Insulin-dependent type 1 diabetes mellitus when there is documentation by the physician of poor diabetic control
    • Cystic fibrosis related diabetes
    • Type 2 diabetes when there is documentation by the physician of poor diabetic control and the patient has failed to achieve glycemic control after six months of multiple daily injection therapy

See Also:

This list of covered services is not all inclusive. TRICARE covers services that are medically necessaryTo be medically necessary means it is appropriate, reasonable, and adequate for your condition. and considered proven. There are special rules or limits on certain services, and some services are excluded.

Last Updated 6/18/2020

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Are you the spouse or surviving spouse of—or a child of—a Veteran with disabilities or a Veteran who has died? If you don’t qualify for TRICARE (the Department of Defense’s health care program for active-duty and retired service members and their families), you may be able to get health insurance through the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA).

Through this program, we cover the cost of some of your health care services and supplies. This is called cost sharing. Find out if you qualify for CHAMPVA and how to apply.

Am I eligible for health care through CHAMPVA?

You may only be eligible for health care through CHAMPVA if you don’t qualify for TRICARE and at least one of the descriptions listed below is true for you.

At least one of these must be true. You’re:

  • The spouse or child of a Veteran who’s been rated permanently and totally disabled for a service-connected disability by a VA regional office, or
  • The surviving spouse or child of a Veteran who died from a VA-rated service-connected disability, or
  • The surviving spouse or child of a Veteran who was at the time of death rated permanently and totally disabled from a service-connected disability, or
  • The surviving spouse or child of a service member who died in the line of duty, not due to misconduct (in most of these cases, family members qualify for TRICARE, not CHAMPVA).

A service-connected disability is a disability that we’ve concluded was caused—or made worse—by the Veteran’s active-duty service. A permanent disability is one that’s not expected to improve.

Note: A Veteran who’s the qualifying CHAMPVA sponsor for their family may also qualify for the VA health care program based on their own Veteran status. If 2 spouses are both Veterans who qualify as CHAMPVA sponsors for their family, they both may now qualify for CHAMPVA benefits. Each time they need medical care, they may choose to get care through the VA health care program or using their CHAMPVA coverage.

What else might affect whether I can get CHAMPVA benefits for myself or a family member?

There are other factors that may affect whether you or other family members qualify for CHAMPVA. Please click on the description that matches your status to learn more:

  • If you’re expecting a baby, you’ll need to take the 2 steps listed below before you can apply for CHAMPVA for your newborn.

    You’ll need to:

    • Get a Social Security number for your baby by applying at the nearest Social Security Administration office, and
    • Set up the baby’s status as a dependent of the Veteran sponsor by contacting your nearest VA regional office.

    Medical claims can’t be paid until you sign your baby up under CHAMPVA, so please get them a Social Security number and set their status as a dependent as soon as possible.

    Find a Social Security office near you
    Find a VA regional office near you

  • If you’re the surviving spouse of a qualifying CHAMPVA sponsor and you remarry before age 55, you no longer qualify for CHAMPVA as of midnight on the date of your remarriage.

    If you remarry on or after your 55th birthday, you can keep your CHAMPVA benefits.

  • If you’re the surviving spouse of a qualifying CHAMPVA sponsor and you remarry, but the remarriage ends by death, divorce, or annulment, you may qualify again for CHAMPVA.

    The first date that you qualify again is the first day of the month after your remarriage ends or December 1, 1999—whichever date is later. You’ll need to provide us with copies of your marriage certificate and death, divorce, or annulment documents (as appropriate).

  • If you’re covered under CHAMPVA and you turn 18 years old, you’ll need to send us proof that you’re enrolled full time in college or another educational institution to keep getting benefits.

  • If you were covered under CHAMPVA as the stepchild of a Veteran, and you leave the Veteran’s household because of a divorce or remarriage, you no longer qualify for CHAMPVA.

  • If you’re a family member caring for a Veteran with disabilities, and you’re not entitled to care or services through another health plan, you may qualify for CHAMPVA.

    If the Veteran you’re caring for was seriously injured in the line of duty on or after September 11, 2001, you may qualify for health care benefits and other caregiver support through the Program of Comprehensive Assistance to Family Caregivers.

  • CHAMPVA is always the second payer to Medicare. Here are some requirements you need to know:

    If you’re under 65 years old, you’re eligible for CHAMPVA if you meet both of the requirements below.
    Both of these must be true. You:

    • Have both Medicare Parts A and B, and
    • Are otherwise eligible for CHAMPVA

    If you’re 65 years old or older, you’re eligible for CHAMPVA if you’re eligible for Medicare. If you turned 65 before June 5, 2001, and you’re entitled to either Medicare Part A or B, you’ll also need to enroll in Medicare Part B to be eligible for CHAMPVA.

    Note: You don’t need to enroll in Medicare Part D to qualify for CHAMPVA.

What benefits do I get with CHAMPVA?

With CHAMPVA, you’ll be covered for services and supplies when we determine they are medically necessary and were received from an authorized provider. When providers are performing services within the scope of their license or certification, we consider them to be authorized.

Covered services include:

  • Ambulance service
  • Ambulatory surgery
  • Durable medical equipment (DME)
  • Family planning and maternity
  • Hospice
  • Inpatient services
  • Mental health services
  • Outpatient services
  • Pharmacy (prescription medicines)
  • Skilled nursing care
  • Transplants

When you’re signed up for CHAMPVA, you’ll get a copy of the CHAMPVA Program Guide. This guide will tell you more about covered and non-covered services and supplies.

  • Download the CHAMPVA Program Guide (PDF)

How do I get CHAMPVA benefits?

You’ll need to apply for these benefits.

To apply, submit these required documents:

  • Application for CHAMPVA Benefits (VA Form 10-10d) (PDF), and

  • Other Health Insurance Certification (VA Form 10-7959c), and

  • Documents related to your Medicare status:

    • If you qualify for Medicare for any reason, you’ll need to submit a copy of your Medicare card.

    • If you’re 65 years old or older and don’t qualify for Medicare, you’ll need to send us documentation from the Social Security Administration that confirms you don’t qualify for Medicare benefits under anyone’s Social Security number.

To speed up the processing of your application, you can also send copies (not originals) of these optional documents:

  • The page from the VBA rating decision showing your Veteran is permanently and totally disabled (or the death rating if you’re a survivor)
  • Your Veteran’s DD214 (Certificate of Release or Discharge from Active Duty)—or, if the Veteran was a World War II or Korean War Veteran, the Report of Separation. If you don’t have a copy of the necessary form, you can request it by submitting a Standard Form 180, Request Pertaining to Military Records, from the National Archives.
    Find out how to request military service records online, by mail, or by fax
  • Documents related to any dependent children you’re including in your application:
    • A copy of each child’s birth certificate or adoption papers
    • School certification of full-time enrollment for children ages 18-23.
      Download our fact sheet on school enrollment certification requirements (PDF)

If you’re a surviving spouse who remarried but is once again single, also send a copy of the legal document that ended your marriage. This may be a divorce decree, death certificate, or annulment decree.

Be sure to sign and date your application. If your Veteran is applying for you as a spouse, be sure to also include the date of the marriage on the application.

Mail your application to:

VHA Office of Community Care
CHAMPVA Eligibility
PO Box 469028
Denver, CO 80246-9028

Or fax it to: 303-331-7809

What happens after I apply?

Once we get your application, we’ll review it to be sure it’s complete and includes all required forms. If it’s not complete, we’ll return it to you with more instructions.
Download application instructions (PDF)

How long will it take to hear back about my application?

If you send us all required and optional documents—and if your application is complete—it’ll take about 6 weeks after we get your package until you get your CHAMPVA ID card and related materials.

Champva Copays

If you send us only the required documents, it may take 2 to 8 months since we’ll need to confirm your information with other federal agencies.

Part

Does Champva Cover Part B Deductible

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Champva Copayment

Get answers to frequently asked questions about CHAMPVA
Find out how to file a CHAMPVA claim
Find out if you can get care at a local VA medical center when you’re covered under CHAMPVA