Help With Prescription Copays

Posted : admin On 1/3/2022

S will therefore pay the plan copay of $1.35 because it is cheaper than the Extra Help copay of $3.70. S had full Extra Help and a monthly income below $1,094, his copays would be $1.30 for generics and $4.00 for brand-name drugs, making his generic Extra Help copay less costly than the plan copay.

Seniors pay a big price for the prescription medications they need to stay healthy, even with Medicare prescription drug coverage. Kaiser Family Foundation research shows the cost of copays for prescriptions often totals thousands of dollars a year for seniors. For some, the financial burden leads to skipping doses, cutting pills in half to make the medication last longer, or simply going without. If you’re having trouble affording your prescriptions, here are some possible sources of help.

Ask about generic drugs—your doctor can tell you if you can take a generic drug instead of a brand. What can we help with? PAF’s Co-Pay Relief (CPR) program provides direct financial assistance to qualified patients with co-payments, co- insurance or cost-sharing associated with prescription drugs through funds dedicated to specific disease states. You'll pay either our full copay rate or reduced copay rate. If you live in a high-cost area, you may qualify for a reduced inpatient copay rate no matter what priority group you're in. To find out if you qualify for a reduced inpatient copay rate, call us toll-free at 877-222-8387. We're here Monday through Friday, 8:00 a.m. Here are 6 tips to consider if you think you might need to get help with the costs of prescription drug coverage. Consider switching to generics or other lower-cost drugs. There may be generic or less-expensive brand-name drugs that would work just as well as the ones you're taking now.

Talk to your doctor about drug cost

It may feel awkward to discuss money with your doctors, but they need to know if you can’t fill your prescriptions because of the cost. Some doctors keep samples from drug company representatives to give to patients who need a little help covering the cost in the short run. Your doctors may also know about coupons and patient assistance programs (more about PAPs below). They may also be able to prescribe a lower-cost generic drug, although generic drug prices are rising, too.

Ask your pharmacist for advice on paying for medication

Pharmacists see the sticker shock their customers face at the register and are usually eager to help. Ask your pharmacist if he or she knows about coupons to help with a one-time prescription or PAPs for medications you need long-term. Some pharmacy chains and grocery stores offer $4 deals on 30-day supplies of common generic drugs. Others have their own prescription discount card programs that offer much lower drug prices to cardholders.

Apply for Medicare’s Extra Help program

If you’re a Medicare beneficiary with a low income and few assets, you may qualify for the Extra Help program even if you’re not eligible for Medicaid or SSI. Extra Help’s upper income limit for a single senior in 2016 is $17,820, with a maximum of $13,640 in assets (including savings, stocks, and bonds). Extra Help recipients may see a reduction in their premium and deductible costs, and prescription copays are currently capped at $2.95 for generics and $7.40 for name-brand medications.

Contact your state health department

Some states have copay assistance programs for low-income residents. The programs are usually open to people with specific illnesses, and availability varies from state to state. Ask your state health department or check the Medicare Rights Center’s national list of state pharmaceutical assistance programs.

Look for prescription assistance programs (PAPs)

The Partnership for Prescription Assistance is a free source of information about drug-company prescription insurance programs. Just enter the name of the drug you need and you’ll see what, if any, PAP can help you cover the cost. You can also search for affordable healthcare clinics in your area.

Connect with non-profit prescription help programs

Many doctors, public health experts, and policymakers have developed non-profit programs to help people pay for their medication. You can search with these three resources:

  • The Medicare Rights Center’s charity copay help list
  • The Patient Advocate Foundation’s Co-Pay Relief website
  • Needymeds.org, a clearinghouse for patient information on affording prescription drugs

You may also be able to free up more money for your medication by getting help with other expenses. Check out these other financial resources for seniors.

Help With Prescription Copays

Casey Kelly-Barton

Casey Kelly-Barton is an Austin-based freelance writer whose childhood was made awesome by her grandmothers, great-grandmother, great-aunts and -uncles, and their friends.

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Due to the passage of the American Rescue Plan in March 2021, copayments for medical care and prescriptions provided by the Veterans Health Administration (VHA) during the period of April 6, 2020 through September 30, 2021 will be canceled. All copayments paid to VA for medical care and prescriptions during the period of April 6, 2020 to present will be refunded.

Please review the COVID-19 Medical Debt Relief page for answers to some common questions.
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Help With Prescription Drug Copays

Enrolled Veterans will be assessed copayments for care or services (including urgent care) based on their eligibility and/or income on file in the VA health care system. For care or services furnished through the Veterans Community Care Program, the same copayment requirements will apply. Copayment rates are listed below.

For information on how to pay your bill or copayment, visit our Billing and Payments page.
Billing and Payments

Veteran Copayments— Published October 6, 2017

You can explore your eligibility for VA health care benefits using the online Health Benefits Explorer or by contacting the VA Call Center.

VA Call Center: 877-222-VETS (8387)
Monday through Friday, 8:00 a.m. – 8:00 p.m. ET

Urgent Care (Community Care)

Veterans may be charged a copayment for urgent care that is different from other VA medical copayments.

  • Copayments depend on the Veteran’s assigned priority group and the number of times an urgent care provider is visited in a calendar year.
  • Copayment charges are billed separately by VA as part of VA’s billing process. There is no limit to the number of times a Veteran can go to an urgent care provider. For more information, visit the OCC Urgent Care page.
    OCC Urgent Care page
Copayment rates for urgent care
Veteran Priority GroupsCopayment Amount
1-5
  • First three visits (per calendar year): $0
  • Fourth and greater visits (per calendar year): $30
6

If related to a condition covered by a special authority:

  • First three visits (per calendar year): $0
  • Fourth and greater visits (per calendar year): $30

If not related to a condition covered by a special authority: $30 per visit

7-8$30 per visit
1-8$0 copay for visit consisting of only a flu shot

Outpatient Care

Outpatient care is defined as primary or specialty care that does not require an overnight stay. Copayments for outpatient care are listed in the table.

NOTE: Veterans who have a service-connected rating of 10% or higher are not required to pay a copayment for outpatient medical care.

Copayment rates for outpatient care
Examples of Outpatient CareCopay
Primary Care Services$15 per visit
Specialty Care Services: Services such as outpatient surgery, dermatology, audiology, optometry, cardiology and specialty tests like MRI or CAT scan.$50 per visit

Inpatient Care

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Inpatient care occurs when a patient’s condition requires admission to a hospital. There are two inpatient copayment rates: the full rate and the reduced rate. Veterans living in high cost areas may qualify for a reduced inpatient copayment rate. Copayment rates for an inpatient hospital stay are listed in the table below.

NOTE: Veterans who have a service-connected disability rating of 10% or higher are not required to pay a copayment for inpatient medical care.

Copayment rates for an inpatient hospital stay
Veteran Priority GroupsCopay
(2021)
Period of Service/Care
Priority Group 7 Veterans
Veterans with gross household incomes below the geographically-adjusted VA income limits for their resident location and who agree to pay copayments.
$296.80First 90 days of care during a 365-day period
$148.40Each additional 90 days of care during a 365-day period
$2Per day charge
Priority Group 8 Veterans
Veterans with gross household incomes above the geographically-adjusted VA income limits for their resident location, who agree to pay copayments, and meet other specific enrollment and service-connected eligibility criteria.
$1,484First 90 days of care during a 365-day period
$742Each additional 90 days of care during a 365-day period
$10Per day charge

Medications

Medication copayments are required for each prescription, including each 30-day (or less) supply of maintenance medications prescribed on an outpatient basis for nonservice-connected conditions. This copayment may change annually.

Medication copayments are also charged for all over-the-counter (OTC) medications (like aspirin, cough syrup, and vitamins) that are dispensed from a VA pharmacy. You may want to consider purchasing over-the-counter medications on your own.

NOTE: There is an annual medication copayment cap of $700 for Veterans in Priority Groups 2 through 8. The medication copayment cap goes by calendar year (January 1 – December 31).

Veterans who have a service-connected rating of 40% or less, and whose income is at or below the applicable national income thresholds may wish to complete a medication copayment exemption test.

VA National Income LimitsVA Financial Assessment information

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Tiered medication copayment rates effective January 1, 2018
Veteran Priority GroupsCopay
Priority Group 1 Veterans
Veterans with VA-rated service-connected disabilities 50% or more disabling or Veterans determined by VA to be unemployable due to service-connected conditions or Medal of Honor recipients.

No copayment
Priority Group 2-8 Veterans
Required to pay for each 30-day or less supply of medication for treatment of nonservice-connected condition (unless otherwise exempt). Limited to $700 annual cap.
IMPORTANT: Some Veterans may qualify for reduced or no-cost prescriptions based on special eligibility factors.
Prescription Drug TierDays of Supply
1‑3031‑6061‑90
Tier 1: Preferred generics$5$10$15
Tier 2: Non-preferred generics and some OTC medications$8$16$24
Tier 3: Brand-name$11$22$33
View the Tier 1 Copay Medication ListView the Tiered Medication List

Additional information on tiered medication copays can be found on the VA Pharmacy Benefits Management Services website.

Geriatrics and Extended Care

Copayments for health care for older Veterans are based on three levels of care—inpatient, outpatient, and domiciliary (see below). Copayment rates will vary from Veteran to Veteran depending upon financial information submitted on VA Form 10-10EC, Application for Extended Care Services.

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NOTE: Copayments for long-term care services start on the 22nd day of care during any 12-month period. There is no copayment requirement for the first 21 days.

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Geriatrics and extended care copayment rates
Inpatient CareCopay
Community Living Centers (formerly known as nursing homes)
VA Community Living Centers are long-term care services provided to Veterans who need a skilled environment for short-term and long-term stays.
Up to $97/day
Respite Care
Respite Care is a service that pays for someone to come to a Veteran's home or for a Veteran to go to a program while your family caregiver takes a break. Respite Care services may be available up to 30 days each calendar year.
Up to $97/day
Geriatric Evaluation
A multidisciplinary team consisting of a doctor, nurse, and several other health providers conduct an evaluation to promote, preserve, or restore a Veteran’s health. The information gained from the Geriatric Evaluation helps you and your family decide what type of services and support would best meet your needs and preferences.
Up to $97/day
Outpatient Senior CareCopay
Adult Day Health Care
Adult Day Health Care is a program Veterans can go to during the day for social activities, peer support, companionship, and recreation. Adult Day Health Care is for Veterans who need skilled services, case management, and assistance with activities of daily living (e.g., bathing and getting dressed); instrumental activities of daily living (e.g., fixing meals and taking medicines); and/or are isolated or your caregiver is experiencing burden. Adult Day Health Care can provide respite care for your family caregiver and can also help you and your caregiver gain skills to manage your care at home.
Up to $15/day
Respite Care
Respite Care is a service that pays for someone to come to a Veteran's home or for a Veteran to go to a program while your family caregiver takes a break. Respite Care services may be available up to 30 days each calendar year.
Up to $15/day
Geriatric Evaluation
A multidisciplinary team consisting of a doctor, nurse, and several other health providers conduct an evaluation to promote, preserve, or restore a Veteran’s health. The information gained from the Geriatric Evaluation helps you and your family decide what type of services and support would best meet your needs and preferences.
Up to $15/day
Domiciliary Care for Homeless Veterans Copay
Short-Term Rehabilitation and Long-Term Health Maintenance Care
VA offers two types of Domiciliary Care: short-term rehabilitation and long-term health maintenance care. This program provides clinically appropriate levels of care for homeless Veterans whose health care needs are not severe enough to require more intensive levels of treatment.
Up to $5/day

Resources

877-222-VETS (8387)
Monday – Friday
8 a.m. – 8 p.m. EST

VA Geriatrics and Extended Care Resources

• VA Geriatrics and Extended Care
• VA Community Living Centers
• Respite Care
• Adult Day Health Care
• Domiciliary Care for Homeless Veterans Program