Form 10-0460a Request for Prescription Drugs from an Eligible Veteran

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Overview

Instructions
51.43 Eligibility Criteria
Eligibility 1) & 2)
Eligibility 3) 50-60%
Eligibility 4) SC Less than 50%
Eligibility 5) Cat Disability
Ineligible Residents

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Sheet 1: Instructions

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Sheet 2: 51.43 Eligibility Criteria

VA Form 10-0460a

OMB Control No: 2900-0883
Estimated Burden: 60 minutes
Expiration Date: xx/xx/20xx

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of this Act. We may not conduct or sponsor, and the respondent is not required to respond to, a collection unless it displays a valid OMB Control Number. The public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, gather the necessary facts and fill out the form. This information is collected under the authority of Title 38 CFR Parts 51 and 58. It is being collected under the medical benefits in the State Homes Program and will be used for that purpose.

Privacy Act Information: It is being collected to enable us to determine your eligibility for medical benefits and will be used for that purpose. The income and eligibility you supply may be verified through a computer matching program at any time and information may be disclosed outside the VA as permitted by law; possible disclosures include those described in the "routine uses" identified in the VA system of records 24VA136, Patient Medical Record-VA, published in the Federal Register in accordance with the Privacy Act of 1974. Disclosure is voluntary; however, the information is required in order for us to determine your eligibility for the medical benefit for which you have applied. Failure to furnish the information will have no adverse affect on any other benefits to which you may be entitled. Disclosure of Social Security number(s) of those for whom benefits are claimed is requested under the authority of Title 38, U.S.C., and is mandatory. Social Security numbers will be used in the administration of veterans benefits, in the identification of veterans or persons claiming or receiving VA benefits and their records and may be used for other purposes where authorized by Title 38, U.S.C., and the Privacy Act of 1974 (5 U.S.C. 552a) or where required by other statute.

Eligibility Criteria

(1) a veteran in receipt of increased VA compensation, or increased VA pension due to being permanently housebound or in need of regular aid and attendance.

(2) a veteran in need of regular aid and attendance who was formerly in receipt of increased pension but whose pension has been discontinued solely by reason of excess income, and whose annual income does not exceed the maximum annual income limitation by more than $1,000.

(3) a veteran who (i) Has a singular or combined rating of 50 percent or 60 percent based on one or more service-connected disabilities or unemployability and is in need of such drugs and medicines; and (ii) Is in need of nursing home care for reasons that do not include care for a VA adjudicated service-connected disability.

(4) a veteran who (i) Has a singular or combined rating of less than 50 percent, based on one or more service-connected disabilities, and is in need of such drugs and medicines for a service-connected disability, and (ii) Is in need of nursing home care for reasons that do not include care for a VA adjudicated service-connected disability.

(5) The veteran is receiving nursing home care or domiciliary care and has been determined to be catastrophically disabled as defined by § 17.36(e) of this chapter.

**SVH may be asked to provide evidence of eligibility during survey**

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Sheet 3: Eligibility 1) & 2)

Last Name

First Name

Last Four SSN

Level of Care (Nursing Home or Domiciliary)

Eligibility Type

Date of Award from Veterans Benefits Administration (VBA)

Eligible (Y/N)

RX #

National Drug Code (NDC)

Drug Name

Strength

Form

Posting Date

Quanity

Unit Cost

Total Cost

Doe

Bob

xxxx

NH

A&A

10/1/2021

Y

123-456

51407-0079-05

Atorvastatin

20

TAB

20210601

31

0.03

$0.93

Doe

Jane

xxxx

DOM

Housebound

12/15/2007

Y

123-4567

51407-0032-10

Clopidogrel

75

CAP

20210601

31

0.05

$1.55

Doe

John

xxxx

NH

A&A discontinued solely by reason of excess income

3/15/2023

Y

123-45678

57896-0303-01

Docusate /Sennosides A and B

1

LIQ

20210601

28

0.02

$0.56

Doe

John

xxxx

NH

A&A discontinued solely by reason of excess income

3/15/2023

Y

123-458

69315-0117-10

Furosemide

40

CAP

20210601

31

0.04

$1.24

Doe

John

xxxx

NH

A&A discontinued solely by reason of excess income

3/15/2023

Y

123-457

45963-0556-11

Gabapentin

300

SYR

20210601

72

0.07

$5.04

Total

$9.32

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Sheet 4: Eligibility 3) 50-60%

Last Name

First Name

Last Four SSN

Level of Care (Nursing Home Only)

Service Connected Percentage (SC %)

Service Connected Condition/s

Date of Award from Veterans Benefits Administration (VBA)

Veteran Approved Per Diem Rate

Eligible (Y/N)

RX #

National Drug Code (NDC)

Drug Name

Form

Strength

Posting Date

Quanity

Unit Cost

Total Cost

Doe

Bob

xxxx

NH

60%

Arthrosclerotic Cardiovascular Disease

6/1/2020

Prevailing

N

123-456

16729-0216-16

Sertraline Hydrochloride

CAP

50

1/15/2022

11

$1.10

$12.10

Doe

John

xxxx

NH

50%

Post Traumatic Stress Disorder

12/1/2008

Basic

Y

123-4567

00904-6401-80

Tamsulosin

INJ

0.4

1/15/2022

6

$3.72

$22.32

Doe

John

xxxx

NH

50%

Post Traumatic Stress Disorder

12/1/2008

Basic

Y

123-45678

57896-0160-16

Acetaminophen

TAB

32

1/15/2022

1

$8.40

$8.40

Total

$30.72

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Sheet 5: Eligibility 4) SC Less than 50%

Last Name

First Name

Last Four SSN

Level of Care (Nursing Home Only)

Service Connected Percentage (SC %)

Service Connected Condition/s

Date of Award from Veterans Benefits Administration (VBA)

Eligible Medications

Veteran Approved Per Diem Rate

Eligible (Y/N)

RX #

National Drug Code (NDC)

Drug Name

Strength

Form

Posting Date

Quanity

Unit Cost

Total Cost

Doe

Bob

xxxx

40%

Diabetes Mellitus

10/31/2012

Lantus

Prevailing

N

123-456

00002-8715-01

Insulin Human Isophane (NPH)/Insulin Human Regular

INJ

2/15/2022

2

13.64

$27.28

Doe

Bob

xxxx

40%

Diabetes Mellitus

10/31/2012

Metformin

Basic

Y

123-4567

60429-0111-10

Metformin Hydrochloride

500

TAB

2/15/2023

125

0.02

$2.50

Total

$2.50

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Sheet 6: Eligibility 5) Cat Disability

Last Name

First Name

Last Four SSN

Level of Care (Nursing Home or Domiciliary)

Eligibility

Date of Award by VAMC

Eligible (Y/N)

RX #

National Drug Code (NDC)

Drug Name

Strength

Form

Posting Date

Quanity

Unit Cost

Total Cost

Doe

Bob

xxxx

NH

Catastrophic Disability

11/18/2020

123-456

51407-0079-05

Atorvastatin

20

20210601

31

0.03

$0.93

Doe

Jane

xxxx

DOM

Catastrophic Disability

1/15/2021

123-4567

51407-0032-10

Clopidogrel

75

20210601

31

0.05

$1.55

Doe

Fred

xxxx

NH

Catastrophic Disability

2/10/2023

123-45678

57896-0303-01

Docusate /Sennosides A and B

1

20210601

28

0.02

$0.56

Total

$3.04

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Sheet 7: Ineligible Residents

Last Name	First Name	Last Four SSN	Level of Care (Nursing Home or Domiciliary)	Reason for Ineligibility
Doe	Bob	xxxx	NH	Prevailing Rate
Doe	Fred	xxxx	DOM	Non-Service Connected
Zzduck	Frank	xxxx	NH	Service-Connected (SC) Less than 50% and no meds prescribed for SC condition
Doe	Velma	xxxx	NH	Private Pay
Doe	Joe	xxxx	NH	Other