Getting care through CHAMPVA

If you’re enrolled in CHAMPVA, you can purchase dental insurance through the VA Dental Insurance Program (VADIP). VADIP offers dental insurance at a reduced cost.

Learn more about the VA Dental Insurance Program

CHAMPVA offers limited vision coverage. CHAMPVA doesn’t cover eyeglasses or contact lenses except in certain cases.

Yes. We cover prescription medications through Meds by Mail and local pharmacies.

For non-urgent prescriptions you take regularly, you can use Meds by Mail. We’ll mail your medications to your home. You won’t pay any costs out of pocket.

Learn more about Meds by Mail

Note: If you have other health insurance with prescription coverage, you can’t use Meds by Mail. This includes prescription coverage through Medicare.

For urgent prescriptions, you can go to a local pharmacy in the OptumRx network. You’ll need to pay 25% of the cost of prescriptions through OptumRx.

Learn about prescription coverage on the OptumRx website

If you go to a pharmacy that’s not in the OptumRx network, you’ll need to pay out of pocket for the prescription. Then you can file a claim for reimbursement. We’ll pay you back for 75% of the cost.

Note: You’ll need to pay the full cost for urgent prescriptions until you meet your annual deductible of $50 (or $100 maximum for your family).

In most cases, you don’t need to get authorization (approval) before you get care through CHAMPVA. But you do need approval for certain types of care.

You need approval for these types of care:

• Inpatient mental health care (when you stay at the facility)
• Care for alcohol or substance use disorders
• Dental care (in limited cases when we cover dental care)
• Organ transplants

Note: If you get medical equipment or mental health care through VA CITI, you don’t need approval first.

To get approval for mental health care, alcohol use, or substance use:

Call us at . If you live outside the U.S., call us at +1-.

Or mail a letter to this address:

Behavioral Health
CHAMPVA
PO Box 500
Spring City, PA 19475

To get approval for all other types of care:

Call us at 800-733-8387 (TTY: 711).

Or mail a letter to this address:

CHAMPVA Authorization
PO Box 500
Spring City, PA 19475

In most cases, we pay the same amount as Medicare or TRICARE for specific services and supplies. We call this the “allowable amount.”

Here’s what you need to know about how you share in the cost of care:

• You have a $50 deductible each calendar year (or $100 maximum for your family): You must pay this amount first for any urgent prescriptions through OptumRx or outpatient care (like office visits) before we start to pay part of these costs. There’s no deductible for inpatient care (when you stay in a hospital).
• You’ll also pay a cost share of 25% of our allowable amount each calendar year. That means that for each service or supply we cover, you’ll need to pay 25% of the cost. If you have other health insurance, you may not need to pay a cost share.
• You won’t pay more than $3,000 per calendar year for each person on the plan. After you pay $3,000, we’ll pay 100% for covered services.

There’s no specific network of CHAMPVA providers.

When you find a new provider, ask if they “accept assignment” from CHAMPVA. This means they agree to accept CHAMPVA insurance and to charge only the allowable amount.

If you go to a provider who doesn’t accept CHAMPVA, we may still cover some of the cost. You’ll need to pay the provider out of pocket and then file a claim for reimbursement. But we’ll only pay our allowable amount. You’ll need to pay any costs above that amount.

Hospitals and hospital-based providers that accept Medicare must also accept CHAMPVA. So, you may want to search for a hospital or provider through Medicare.

Find a hospital or provider on the Medicare website

After you apply for CHAMPVA, we’ll send you an ID card by mail. It may take up to 6 weeks to get your card after you apply.

If you need a replacement card, call us at (TTY: 711). We’re here Monday through Friday, 8:05 a.m. to 7:30 p.m. ET.

If you have CHAMPVA, you may be able to get care at your local VA health facility through the CHAMPVA In-House Treatment Initiative (CITI).

Here’s what to know about CITI: 

• We cover the entire cost of care and services you get through CITI. 
• The types of care you can get through CITI depend on your local facility.  
• If your facility can’t provide the care you need, they may refer you to a local provider in our community care network. You’ll need to pay part of the cost for this care. 
• If you’re eligible for Medicare, you can’t get care through CITI. Other health insurance may also affect your eligibility.

Contact your local VA health facility to find out if they participate in CITI and check your eligibility.

Find your local VA health facility

If you have questions about CITI, contact your local VA health facility. Or call us at 800-733-8387 (TTY: 711). We’re here Monday through Friday, 8:05 a.m. to 7:30 p.m. ET. 

If you’re eligible for Medicare, you must have Medicare Part A and Part B in order to get or keep CHAMPVA benefits. A Medicare Advantage plan (also called Plan C) also meets this requirement.

Most people become eligible for Medicare at age 65. You may become eligible for Medicare before age 65 if you meet one of these requirements:

• You get Social Security Disability Insurance (SSDI) benefits, or
• You have end-stage kidney disease or ALS (amyotrophic lateral sclerosis)

When you turn 65, you must provide proof of your Medicare coverage to keep your CHAMPVA benefits. If you’re not eligible for Medicare when you turn 65, you must provide a document called a “notice of disallowance” from the Social Security Administration.

Note: You don’t need Medicare Part D to get CHAMPVA.

If you have other insurance with prescription coverage, you can’t use Meds by Mail. But you can still go to local pharmacies in the Optum Rx network.

Tell the OptumRx pharmacy that you have CHAMPVA and other prescription coverage. If both insurances cover your prescriptions, you won't need to pay a cost share.

If you have prescription coverage through Medicare Part D and you want to use Meds by Mail instead, you can cancel your Part D coverage. Follow these steps:

1. Contact CHAMPVA. Ask for a “letter of creditable coverage.” This shows that CHAMPVA provides as much prescription coverage as Medicare Part D.
2. Send the letter to Medicare and ask them to cancel your Part D coverage.

Yes. CHAMPVA is the secondary payer to Medicare. This means that Medicare pays for your care first. Then, CHAMPVA may cover costs that you still owe after Medicare pays.

CHAMPVA is the secondary payer to most other health insurance programs. So if you have other insurance, CHAMPVA will likely be your secondary insurance.

CHAMPVA is always the secondary payer except to these programs:

• Medicaid
• State Victims of Crime Compensation Programs
• Indian Health Services
• Supplemental CHAMPVA policies

If you have other health insurance, your health care provider should bill the other insurance first. The provider should then submit the explanation of benefits (EOB) from the other insurance along with the claim for reimbursement to CHAMPVA.

Note: If you don’t have other health insurance, CHAMPVA will be the primary payer for you. CHAMPVA counts as minimum essential coverage under the Affordable Care Act.

Yes. Medicare Advantage plans (also called Medicare Part C) include original Medicare (also called Medicare Parts A and B). If you’re eligible for Medicare, you must have Medicare Parts A and B to get CHAMPVA. A Medicare Advantage plan meets this requirement.

CHAMPVA is the secondary payer to Medicare. This means that your Medicare Advantage plan will pay for your care first. Then, CHAMPVA may cover costs that you still owe after Medicare pays.

CHAMPVA will cover some or all of your Medicare Part B deductible for outpatient care. A deductible is an amount you need to pay yourself before your insurance starts to pay.

If the remaining part of your Medicare Part B deductible is more than the CHAMPVA allowable amount for your claim, you’ll need to pay your provider the difference between your remaining deductible and the allowable amount.

Note: CHAMPVA doesn’t cover Medicare Part B premiums (monthly payments for insurance coverage). You’ll need to pay these premiums yourself.

The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is a VA program. CHAMPVA is for the spouses, dependents, and survivors of Veterans and service members who meet certain service-connected disability requirements.

TRICARE is a Defense Department (DOD) program. TRICARE (formerly called CHAMPUS) is for active-duty and retired service members, their families, and their survivors.

If you’re eligible for TRICARE, you can’t get care through CHAMPVA.

Learn more about TRICARE on the TRICARE website 

Learn more about CHAMPVA benefits

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

To avoid a gap in benefits between your high school graduation and your first college term, you can send us your college acceptance letter.

You must send us a school certification letter within 1 month after your first school term begins. You’ll need to recertify at least once a year.

Ask your school to write us a letter on school letterhead that includes all of these pieces of information:

• Your full name and the last 4 digits of your Social Security number
• Your estimated graduation date
• Your enrollment status (full-time or part-time)
• Start and end dates for the semester or term
• Signature and title of a school official

You or your school can mail the letter to this address:

VHA Office of Integrated Veteran Care
CHAMPVA Eligibility
PO Box 137
Spring City, PA 19475

Or you or your school can fax the letter to 1-.