| Effective Date:10/10/2013 |
Title:Breast Cancer Prophylaxis
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| Revision Date:11/01/2014
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Document:BI430:00
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| CPT Code(s):None
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Public Statement
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Effective Date:
a)
This policy
will apply to all services performed on or after the above revision date which
will become the new effective date.
b)
For all
services referred to in this policy that were performed before the revision
date, contact customer service for the rules that would apply.
1. Tamoxifen
(Soltamox) and Raloxifene (Evista) are considered a preventive benefit, for
breast cancer prophylaxis in women at high risk for breast cancer.
2. Raloxifene
requires pre-authorization.
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Medical Statement
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1)
Tamoxifen is
covered as a preventive benefit under the following criteria:
a)
The member is
female age 35 years or more AND;
b)
There is no
previous history of breast cancer or Lobular Carcinoma In Situ (LCIS) or Ductal
Carcinoma In Situ (DCIS) AND;
c)
The member
has a 5 year cancer risk > 3% using National Cancer Institute Breast Cancer Risk
Assessment Tool, located at:
http://www.cancer.gov/bcrisktool/
2)
Raloxifene(Evista) is covered as a preventive benefit when the above criteria
are met AND tamoxifen cannot be used. Raloxifene requires pre-authorization
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Limits
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Intentially left empty
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Reference
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USPSTF
Guidelines at:
http://www.uspreventiveservicestaskforce.org/uspstf13/breastcanmeds/breastcanmedsrs.htm#consider
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Application to Products
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This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
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Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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