Getting care for spina bifida and other birth defects

We cover health care services and supplies you need for any health condition—not only for spina bifida.

You can learn more about covered and non-covered services and supplies in the SBHCBP program guide.

Get the SBHCBP program guide to download on our Veterans Health Administration website

We don’t cover these types of services:

• Care that isn’t accepted by VA or the U.S. medical community (including experimental treatments and medications that aren’t approved by the FDA)
• Care you receive as part of a grant, study, or research program
• Services that are outside the scope of the provider’s license or certification
• Services from providers who are suspended or sanctioned by a federal agency
• Services, treatments, or supplies that you don’t have to pay for by law

We only cover health care services and supplies that you need to treat your covered birth defect and related health conditions. We encourage you to keep your primary health insurance for other health care needs.

You can learn more about covered and non-covered services and supplies in the CWVV program guide.

Get the CWVV program guide to download on our Veterans Health Administration website

We don’t cover these types of services for any health conditions:

• Care that isn’t accepted by VA or the U.S. medical community (including experimental treatments and medications that aren’t approved by the FDA)
• Care you receive as part of a grant, study, or research program
• Services that are outside the scope of the provider’s license or certification
• Services from providers who are suspended or sanctioned by a federal agency
• Services, treatments, or supplies that you don’t have to pay for by law

Yes. The SBHCBP covers the full cost of your prescription medications. The CWVV program covers the full cost of prescription medications only for your covered birth defect and related health conditions.

For non-urgent prescriptions you take regularly, you can use Meds by Mail. We’ll mail your medications to your home.

Learn about Meds by Mail

For urgent prescriptions, you can go to a local pharmacy in the OptumRx network.

• For the SBHCBP, they’ll submit the claim for you. You don’t pay any costs out of pocket.
• For the CWVV program, you’ll pay the full cost out of pocket the first time you fill each prescription. Then you can file a claim for reimbursement. If we determine we can cover the prescription, you can get refills through OptumRx at no cost.

Learn more about OptumRx

If you go to a pharmacy that’s not in the OptumRx network, you’ll always pay the full cost out of pocket. Then you can file a claim for reimbursement.

Learn how to file a claim for reimbursement

No. You don’t have any copays or deductibles for covered care. We pay 100% of the allowable amount (the maximum amount we can pay for a covered service).

And providers can’t bill you for any costs after we’ve paid for your care. If your provider agrees to accept payment from this program, they can’t charge you more than the allowable amount.

Note: For the CWVV program, remember that we only cover care related to your covered birth defect.

These programs don’t have lists of approved providers. You can choose any provider who has a state license or certificate for the type of care you need. Or you can choose a provider approved by the Centers for Medicare and Medicaid Services, TRICARE, or the Joint Commission.

Find a provider through the Medicare website

Find a provider through the TRICARE website

Before you get care, make sure your provider will accept the SBHCBP or CWVV as payment in full.

You may also be able to get care at a VA health facility. Contact your nearest VA health facility to find out if they provide care through the SBHCBP or CWVV.

Find your nearest VA health facility

In most cases, you don’t need to get authorization (approval) before you use these programs. But you do need approval before you can get certain types of care.

You need approval for these types of care:

• Dental care
• Medical equipment that costs more than $2,000 to rent or buy
• Outpatient day health care
• Outpatient mental health care (if you have more than 23 visits per year)
• Care for substance use disorder
• Organ transplants

You also need approval for these types of services:

• Attendants (health care providers, friends, or family members who travel with you to health appointments)
• Home care related to your health, such as help preparing meals or keeping your home clean

If you’re filing a claim for travel costs other than mileage, you’ll also need approval for those travel costs.

Your provider should submit the authorization request for you.

If your provider doesn’t submit the request, you can submit it yourself by phone, fax, or mail. Use the phone or fax options for urgent requests.

Provide the following information with your request:

• Your name
• Your Social Security number
• The provider’s name, address, and telephone number
• A description of the service, including procedure and diagnosis codes
• The medical reason you need the service
• The estimated cost (if you know it)
• The date you expect to receive the service

Option 1: By phone

Call us at 833-930-0816 (TTY: 711).

Option 2: By fax

Fax your request to this number: 1-.

Option 3: By mail

For the SBHCBP, mail your request to this address:

VHA Office of Integrated Veteran Care
Spina Bifida Health Care Benefits Program
PO Box 400
Spring City, PA 19475

For the CWVV program, mail your request to this address:

VHA Office of Integrated Veteran Care
CWVV Health Care Benefits Program
PO Box 400
Spring City, PA 19475