The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) offers health benefits to eligible spouses, dependents, and survivors of veterans. Navigating prescription coverage, especially for weight management medications like Wegovy, can be complex. This article aims to clarify CHAMPVA's coverage policies regarding weight loss medications, including Wegovy, and outline steps for accessing these benefits.
CHAMPVA's Healthcare Coverage
CHAMPVA shares the cost of certain healthcare services and supplies with its beneficiaries. Enrollees can also purchase dental insurance through the VA Dental Insurance Program (VADIP), with CHAMPVA offering limited vision coverage.
General Coverage Guidelines
CHAMPVA generally covers most healthcare services and supplies. In most cases, pre-authorization is not required. CHAMPVA typically pays the same amount as Medicare or TRICARE for specific services and supplies.
Cost-Sharing Details
- Deductible: A $50 deductible applies each calendar year (or $100 maximum for the family). This must be paid before CHAMPVA starts covering outpatient care and urgent prescriptions through OptumRx.
- Cost Share: After the deductible, beneficiaries pay a 25% cost share of CHAMPVA's allowable amount for each service or supply.
- Out-of-Pocket Maximum: The maximum out-of-pocket cost for an entire household is $3,000 each calendar year.
When seeking care, it's advisable to ask providers if they "accept assignment" from CHAMPVA. If a provider doesn't accept CHAMPVA, beneficiaries may need to pay out of pocket and file a claim for reimbursement, with CHAMPVA only covering its allowable amount. Hospitals accepting Medicare must also accept CHAMPVA.
CHAMPVA as Secondary Insurance
If a beneficiary has other health insurance, CHAMPVA acts as the secondary payer. The other insurance should be billed first. CHAMPVA is considered minimum essential coverage under the Affordable Care Act and provides IRS Form 1095-B annually upon request. It's important to inform OptumRx pharmacies about any other prescription coverage in addition to CHAMPVA.
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Medicare and CHAMPVA
For beneficiaries eligible for Medicare, enrollment in both Medicare Part A and Part B is required to maintain CHAMPVA benefits. Medicare pays first, with CHAMPVA as the secondary payer. Medicare Advantage plans (Part C) also follow this rule. CHAMPVA may cover some or all of the Medicare Part B deductible for outpatient care but does not cover Medicare Part B premiums.
Wegovy and Weight Management Medications
Weight management medications have become an increasingly discussed topic within healthcare, particularly for individuals seeking assistance with weight loss and related health improvements. Medications like Wegovy, Zepbound, Ozempic and others have gained attention for their potential in aiding weight management when combined with lifestyle interventions.
Accessing Wegovy Through Insurance
Novo Nordisk, the maker of Wegovy, offers a platform to check insurance coverage and access potential savings offers.
Checking Coverage
- Online Tool: Start by using the "check your Cost and Coverage" button on the Novo Nordisk website.
- Information Input: You'll be asked to specify whether you're a patient or caregiver and then provide insurance details. Key information such as name, date of birth, gender, and zip code will be required.
- Healthcare Professional Details: Enter your prescribing healthcare professional's first and last name, city, and state.
- Coverage Status: Based on the submitted information, the tool will indicate whether your insurance covers Wegovy.
Potential Outcomes
- Coverage: If covered, discuss with your healthcare professional whether Wegovy is appropriate for you. A savings card may be available to lower out-of-pocket costs, though government-insured patients cannot use manufacturer copay cards.
- Prior Authorization: If coverage requires prior authorization, your healthcare professional will need to complete a form for the insurance company to review. The insurer will then communicate their decision.
- Not Covered: If Wegovy is not covered, you may submit an appeal or request for coverage with the help of your healthcare professional.
- Undetermined: If coverage is undetermined, more information is needed.
VA Weight Management Programs
For Veterans, the VA offers comprehensive weight management programs and may provide weight management medications under specific conditions.
MOVE! Program
The MOVE! (Managing Overweight/Obesity for Veterans Everywhere) program is designed to equip Veterans with the tools for healthy eating, physical activity, and weight loss. It aims to reduce health risks, prevent or reverse diseases, improve quality of life, and potentially extend lifespan.
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Eligibilty for MOVE!
To qualify for MOVE!, Veterans must:
- Be receiving care from the VA.
- Have a Body Mass Index (BMI) equal to or greater than 25.
MOVE! Program Options
- MOVE! Groups: Weekly appointments covering nutrition, physical activity, and behavior change, led by registered dietitians, clinical psychologists, and nurses.
- TeleMOVE!: Up to six months of daily education reminders and frequent contact with a TeleMOVE! Care Coordinator.
- MOVE! Coach Mobile App: A mobile app for independent weight management.
Weight Management Medications (WMM) at the VA
The VA provides weight management medications for Veterans who meet specific eligibility requirements.
Eligibility Requirements for WMM
To be eligible for medication, patients must participate in a Comprehensive Lifestyle Intervention (CLI) addressing diet, physical activity, and behavioral changes. Additionally, the patient must meet one of the following BMI criteria:
- BMI is 30 or higher, or
- BMI is between 27 and 29.9, and the patient has at least one weight-related health condition (e.g., hypertension, type 2 diabetes, dyslipidemia, metabolic syndrome, obstructive sleep apnea, osteoarthritis, metabolic dysfunction-associated steatotic liver disease).
WMM can be initiated after the patient enrolls in a CLI and shows satisfactory participation.
Available WMM at VA
The VA offers several FDA-approved weight management medications:
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- Oral Medications:
- Orlistat (Xenical)
- Phentermine/topiramate (Qsymia)
- Bupropion/naltrexone (Contrave)
- Injectable Medications (Non-Formulary):
- Tirzepatide (Zepbound)
- Semaglutide (Wegovy)
Medication Availability
Oral medications are typically available, while injectable medications have faced scarcity issues since 2021 due to drug supply chain issues, limited providers, access to CLI, and budgetary constraints.
Filling Non-VA Prescriptions at the VA
Any VA primary care provider can submit a request to continue weight management treatment for continuity of care. Patients receiving treatment from a non-VA provider must meet the VA's scarce resource guidance eligibility tiers and provide documentation verifying they meet the criteria.
Prescriptions for Outside Pharmacies
The decision to provide a prescription for an outside pharmacy lies with the prescribing healthcare provider within the VA. Weight management medication refills cannot be picked up at the Outpatient Pharmacy.
Clarification on Medications
Medications like Ozempic (semaglutide), Victoza (liraglutide), and Mounjaro (tirzepatide) are not FDA-approved for weight loss but are used for type 2 diabetes management.
Weight Loss Surgery
Weight loss surgery is available for Veterans who have difficulty managing their weight despite other methods or who have an obesity-related health condition. Patients must participate in a CLI to qualify for surgery.
Accessing Prescriptions Through CHAMPVA
CHAMPVA beneficiaries can access prescriptions through OptumRx.
Urgent Prescriptions
For urgent prescriptions, beneficiaries can visit a local pharmacy in the OptumRx network. For out-of-network pharmacies, they must pay out of pocket and file a claim for reimbursement.
Refilling Prescriptions
The fastest ways to refill prescriptions are online or by phone, with processing and delivery taking up to 10 days.
Renewing Prescriptions
If a prescription expires or runs out of refills, beneficiaries can call CHAMPVA to request a prescription renewal.
New Prescriptions
New prescriptions may take up to 21 days for processing and delivery. Beneficiaries can ask their provider to use their electronic prescribing system or send the original prescription to OptumRx.
Additional Information
Community Care Network
The types of care available through the Community Care Network (CITI) depend on the local facility. If the facility cannot provide the necessary care, they may refer the beneficiary to a local provider in the network. Individuals eligible for Medicare cannot receive care through CITI.
Updating Information
To update an address or for other inquiries, beneficiaries can contact CHAMPVA.