Certain preventive
medications ordered via a valid prescription are covered at zero cost-share to
members in non-grandfathered group or individual plans. Documentation must be
provided with a specific request for coverage of the products at no cost share
so a prior authorization (PA) can be entered. Coverage criteria are outlined
below.
1)
Contraceptives (see
BI372)
2)
Immunizations (see BI022)
3)
Tobacco cessation
products (see BI183)
4)
Aspirin to prevent
cardiovascular disease in adults age 50 to 59
5)
Low-dose aspirin (81mg)
for pregnant women after 12 weeks of gestation who are at high risk for
preeclampsia (PA required).
6)
Oral fluoride
supplementation for preschool children older than 6 months and up to 5 years of
age whose primary water source is deficient in fluoride.
7)
Folic Acid
supplementation, including prenatal vitamins containing folic acid for women <
55 years of age. Prescription folic acid products are excluded as well as any
product containing > 0.8mg or < 0.4mg of folic acid.
8)
Bowel Prep agents for
colorectal cancer screening – Generic prescription bowel preparation agents for
adults 50 years of age or older. To
ensure appropriate utilization, a quantity limit of one (1) bowel preparation
product per year applies. Branded bowel preparation products are not covered
under the preventive benefit but may be covered under the standard pharmacy
benefit.
9)
Breast cancer preventive
medications are covered subject to the criteria below (PA required).
For tamoxifen:
a)
The member is a female
age 35 years or older 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
www.cancer.gov/bcrisktool/
d)
For raloxifene,
anastrozole, or exemastane criteria above must be met and member must be unable
to take tamoxifen.
10)
Select low to moderate
dose statins (lovastatin 20-40mg/day, atorvastatin 10-20mg/day, and simvastatin
10-40mg/day only) are provided to members meeting the following conditions (PA
required):
a)
Age 40-75 years of age
AND
b)
No history of
cardiovascular disease (CVD) AND
c)
One or more CVD risk
factors (dyslipidemia (defined as LDL-C >130mg/Dl or HDL < 40mg/Dl),
diabetes, hypertension, or smoking) AND
d)
A calculated 10-year CVD
event risk of 10% or greater (use
http://www.cvriskcalculator.com/)
e)
11)
For members at high-risk of HIV
acquisition, preexposure prophylaxis (PrEP) antiretroviral therapy (tenofovir,
Truvada, Descovy) is covered for members meeting the criteria below (PA
required).
i)
Member is taking
tenofovir disoproxil fumarate or Truvada as effective antiretroviral therapy for
preexposure prophylaxis (PrEP) AND
ii)
Will be used as part of a
comprehensive prevention strategy including other preventive measures AND
iii)
For Descovy, member must
have a contraindication or history of intolerance to Truvada.