Pharmacy Services and Durable Medical Equipment
CCN covers routine medically necessary medication that’s part of an authorized episode of care and follows the rules of the VA National Formulary. CCN also covers medication that’s needed on an urgent and/or emergent basis.
- Urgent or emergent medication must be on the Urgent/Emergent Formulary.
- For medication that’s not on VA’s National Formulary, the provider needs to contact the Veteran’s authorizing VAMC, request a Formulary Request Review Form, fill out the form, and submit it back to the VAMC for approval or denial.
For all medications, including urgent and emergent, TriWest uses the Express Scripts (ESI) pharmacy network.
Urgent and emergent medications do NOT require an approved referral/authorization. However, for medication prescribed during an urgent care or retail walk-in clinic visit, clinic staff must FIRST call TriWest at 833-4VETNOW (833-483-8669) to confirm Veteran eligibility in order for the medication to be approved for fulfillment by the pharmacy.
Real-time urgent/emergent pharmacy dispensing information is available on Availity in the TriWest Payer Space. As per U.S. Drug Enforcement Administration (DEA) policies, some controlled substances will require the Veteran bring a hard copy of the prescription to the overseeing VA medical facility or CCN pharmacy.
General/Routine Prescriptions
VA handles all general/routine medication fulfillments directly. To prescribe routine, non-urgent/non-emergent medicine:
- Prescribe the medicine in accordance with VA’s National Formulary.
- Fax both the prescription and a copy of the approved referral/authorization to your local VA Pharmacy for processing and fulfillment within one hour of seeing the Veteran.
- The Veteran may pick up the medicine at the VA Pharmacy or an ESI pharmacy.
- Do NOT dispense medication samples to Veterans.
- The provider must be registered with the state’s prescription monitoring program.
If the Veteran needs a medication that’s NOT on VA’s National Formulary, providers will need to take a few additional steps before prescribing:
- Contact the local VAMC and ask for a Formulary Request Review Form. Fill out the form and return it to the VAMC.
- VA will either approve or deny the request.
- If approved, continue prescribing the medication as described above.
Urgent/Emergent Medicine
When there is an urgent/emergent need to start a medication and it is not possible to fill the prescription at a VA Pharmacy, the provider may write a prescription for up to a maximum 14-day supply (without refills).
- Send the prescription and a copy of the approved referral/authorization to an ESI retail pharmacy, preferably through the Surescripts e-Prescribing tool. To learn more about Surescripts and to register, go to the website.
- When it is medically necessary to continue the medicine beyond the initial 14-day supply, write a second prescription and fax it to the VA’s authorizing facility pharmacy within one hour of seeing the Veteran.
- Providers can now utilize e-prescribing to push prescriptions to a VA Pharmacy, VA’s preferred method. VA’s next preferred method is via fax.
Providers must check with their state’s prescription monitoring program for any controlled substance utilization prior to writing any controlled substance prescription for a Veteran to ensure appropriate opioid/controlled substance use.
Veterans who consent to participate in Human Subject Research studies and are enrolled in clinical trials CANNOT be authorized for those services under CCN. Veterans must be referred back to their respective Non-VA Care Office for the administration and coordination of non-VA care associated with clinical trials.
What to Include in All Prescriptions
VA requires that prescribing providers under CCN include the following information for prescriptions:
- Provider’s Name (Family, Given, Middle Suffix) Provider Name Suffix (e.g., Sr., Jr., II. III.)
- Provider’s National Provider Identifier (NPI)
- Provider’s Tax ID Number (TIN)
- Provider’s personal DEA Number and expiration date (not a generic facility number)
- Provider’s office address
- Provider’s office phone and additional phone number
- Provider’s fax number (if applicable)
- Provider’s discipline (e.g., physician, physician assistant, nurse practitioner)
Durable Medical Equipment (DME)
VA is the primary resource for all routine DME for Veterans. For urgent or emergent care, providers may directly supply Veterans with urgent/emergent DME and TriWest will reimburse providers. Urgent or emergent DME examples include: splints, crutches, canes, slings, or soft collars.
To Order Non-Urgent or Non-emergent DME
- To have routine DME (to include eyeglasses) authorized and provided to the Veteran, complete the VA’s RFS form. The RFS form is available on the VA Storefront.
- On the VA Storefront homepage under “For Providers” on the left-hand navigation bar, click the “Request and Coordinate Care” menu item.
- Next, click “Request for Services Requirements.” The link to the RFS form will be at the bottom of that section.
An RFS form must be fully completed to include the DME section and, if ordering eyeglasses, the measurement for frames. After completing the RFS form, fax it to the authorizing VAMC within 24 hours. VA will then directly coordinate the DME between the provider and the Veteran.
Do NOT dispense non-urgent or non-emergent DME out of your office unless you receive VA approval.
Requests for exceptions to this requirement may be considered under special circumstances.
All DME and medical device prescriptions must include the following information:
- Date of Request
- Description and HCPCS Code for Each Prescribed Item
- Detailed Information (brand, make, model, part number, etc.)
- Diagnosis and International Classification of Diseases (ICD-10 Code(s)
- Item Delivery Location/Address and Expected
- Delivery Date
- Medical Justification for Each Prescribed Item (if a specific brand/model/product is prescribed)
- Medical Provider’s Signature
- Patient Education was completed or mailed to provider to finalize education
- Patient’s Date of Birth
- Patient’s Full Name
- Patient’s Last 4 Digits of SSN
- Patient’s MVI ICN
- Prescribing Provider’s Address
- Prescribing Provider’s Fax Number
- Prescribing Provider’s Full Name
- Prescribing Provider’s Phone Number
Providers are responsible for all necessary DME follow-up care, including patient education, training, fitting, and adjustment for the prescribed item. VA will procure and send the DME to the prescribing provider, unless specified otherwise.
VA reserves the right to issue comparable, functionally equivalent DME and Medical Devices to what is prescribed by the provider.
Hearing Aids: Submit prescriptions for hearing aids to VA for review and fulfillment. Providers must provide VA with initial testing results related to potential hearing aid needs. Providers cannot purchase or provide hearing aids under this contract. VA will provide information for the hearing aid manufacturers that have current contracts with VA.
Home Oxygen: Submit requests for home oxygen to VA for review and fulfillment. Providers must provide definitive testing results related to potential home oxygen needs and detailed home oxygen prescriptions. Providers cannot purchase or provide home oxygen equipment or supplies under this contract.
Oral Appliance Therapy: TriWest shall provide the capability for eligible Veterans to receive Oral Appliance Therapy (OAT) for obstructive sleep apnea through the Dental Network (managed by Delta Dental). OAT is classified as medical treatment for a medical disorder, obstructive sleep apnea, which is provided by a licensed dentist.
To order urgent or emergent DME:
- DME must be provided to a Veteran by a treating physician, facility, or DME supplier at the time of treatment and before the Veteran leaves the provider’s care site. A pre-approved referral/authorization for urgent/ emergent DME is NOT required.
- Bill TriWest for the urgent or emergent DME and TriWest will reimburse according to the provider contract.
- Failure to plan or coordinate DME needs in advance of a scheduled procedure does not constitute an urgent or emergent need.
- Any supplied DME must include follow-up care, patient education, training, fitting, and adjustment for the prescribed item as part of the supplier’s responsibility.
If authorized, no rentals are to exceed 30 days.