Attachment 3 - Excluded Items.pdf
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- Attached to
- R408--FY24 IVC PHARMACY BENEFIT MANAGER
- Solicitation number
- 36C79123R0007
About this file
This document outlines excluded items and services under the CHAMPVA Pharmacy Benefits program managed by the Department of Veterans Affairs Veterans Health Administration. Specifically excluded are cosmetic drugs and medicines, weight loss medications, most vitamins, nutritional supplements, smoking cessation drugs and supplies, opioid dependency medications substituted for other addictive drugs, and over-the-counter items except for certain conditions. Also excluded is treatment of general dental health issues or pain from poor dentition regardless of provider or systemic cause, as well as compound medications containing certain specified ingredients such as baclofen, bupivacaine, and others listed. A related federal contract opportunity is also provided for a FY24 pharmacy benefit manager for Veterans Integrated Service Network 19 to manage the CHAMPVA program.
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Text version
Department of Veteran Affairs Veteran’s Health Administration
Veteran Family Member Programs Pharmacy Benefits Manager
ATTACHMENT 3, EXCLUDED ITEMS
Policy: CHAMPVA Policy Manual
CHAPTER: 2
SECTION: 22.1
TITLE: PHARMACY EXCLUSION(S)
Cosmetic type items D. Drugs and medicines prescribed in connection with cosmetic surgery that is performed to primarily improve physical appearance or for psychological purposes to restore form without correcting or materially improving a bodily function.
Weight loss medication E. Drugs and medicines prescribed for nonsurgical treatment of obesity, dietary control, or weight reduction
Vitamins (except-Folic Acid 1mg, Cyanocobalamin injection, Vitamin K, Ergocalciferol) G. Vitamins or other nutritional supplements when not used as a specific treatment of a covered medical condition.
Nutritional Supplements (tablets/capsules) G. Vitamins or other nutritional supplements when not used as a specific treatment of a covered medical condition
Smoking cessation drugs and supplies H. Smoking cessation drugs and supplies, such as nicotine patches.
Opioid dependency medications I. Prescriptions to be utilized in drug maintenance programs where one addictive drug is substituted for another, such as methadone substituted for heroin.
OTC (over the counter) except for Spina Bifida (SB) and Children of Women Vietnam Veterans (CWVV) J. All drugs, including compounded preparations, not requiring a prescription (over-the-counter purchases) except for insulin and related diabetic testing supplies and syringes.
Department of Veteran Affairs Veteran’s Health Administration
Veteran Family Member Programs Pharmacy Benefits Manager
Policy: CHAMPVA Policy Manual
CHAPTER: 2
SECTION: 5.1
TITLE: ADJUNCTIVE DENTAL CARE EXCLUSION(S)
Dental Caries A. The treatment of generally poor dental health (dental caries) or dental pain associated with poor dentition, regardless of the place of service or type of provider or if due to certain systemic causes, such as congenital syphilis, rickets, malabsorption syndromes, eating disorders, and diabetes.
Excluded Compound Ingredients:
As found on https://www.va.gov/COMMUNITYCARE/programs/dependents/pharmacy/index.asp
• Baclofen Powder
• Bupivacaine HCL Powder
• Cyclobenzaprine HCL Powder
• Diclofenac Sodium Powder
• Ethoxy Diglycol Liquid
• Flurbiprofen Powder
• Fluticasone Propionate Powder
• Gabapentin Powder
• Ketamine HCL Powder
• Ketoprofen Micronized Powder
• Levocetrizine Dihydrocloride Powder
• Lipoderm Base
• Lipo-Max Cream
• Lipopen Plus Cream
• Lipopen Ultra Cream Base
• Meloxicam Powder
• Mometasone Furoate Powder
• Nabumetone Micronized Powder
• Pracasil TM-Plus Gel
• Prilocaine HCL Powder
• Resveratrol Powder
• Spira-Wash Gel
• Tramadol HCL Powder
• Versapro Cream Base
• Versatile Cream Base https://www.va.gov/COMMUNITYCARE/programs/dependents/pharmacy/index.asp
File details come from the government source that posted it. Updated .