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VA Code in Flight Submission - Fixed Medication Co-Payment Tiers SDD, RSD and Patch Descriptions code and docs.
Please use this identifier to cite or link to this publication: http://hdl.handle.net/10909/11154
Submitted by OI&T EPMO Lean Systems Engineering Open Source Coordination Office on 10-04-2016.
The Fixed Medication Copayment Tiers (FMCT) project is a redesign and/or enhancement of the current structure of charges for first-party pharmacy claims for medication required on an outpatient basis to treat non-service connected conditions. This project brings the Department of Veterans Affairs (VA) into compliance with the Proposed Rule 38 Code of Federal Regulations (CFR) Part 17 Copayments for Medications. This rulemaking eliminates the Medical Consumer Price Index (CPI-P) formula used to calculate future rate increases and establishes the following three classes of medications, identified as Tier 1, Tier 2, and Tier 3, beginning February 2017:

• Tier 1 = $5 for a 30-day or less supply of a medication;
• Tier 2 = $8 for a 30-day or less supply of a medication; and
• Tier 3 = $11 for a 30-day or less supply of a medication.

In addition to the rule, Pharmacy Benefits Management (PBM) requests the addition of Tier 0 for excluded and exempt products with no copayment.

In order to comply with this change to Federal regulations, it will be necessary to update Information Technology (IT) systems to conform with changes to qualified prescription medications within the VA Pharmacy Product System (PPS), Veterans Health Information Systems and Technology Architecture (VistA) and VA National Drug Files (NDFs) and Local Drug Files, to establish fixed copayment amounts depending on the class of medication (Tier 0, Tier 1, Tier 2, or Tier 3), while still maintaining the utility of the $700 copayment cap per calendar year for PG 2-8, as applicable, on an individual Veteran basis.

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