Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

Use the index below to search for coverage information on specific medical conditions.

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QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.


Effective Date: 01/01/2014 Title: Preventive Care Medications
Revision Date: 07/01/2020 Document: BI448:00
CPT Code(s): None
Public Statement

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)    This policy applies to all group and individual non-grandfathered plans, including ASO groups using OptumRx.

2)    Certain preventive medications ordered via a valid prescription are covered at zero cost shares to members.

3)    QualChoice uses the United States Preventive Services Task Force (USPSTF) recommendations to determine which preventive medications are covered.  These guidelines are periodically updated so this list is subject to change.

4)    USPSTF recommendations of Grade A or B are implemented.

5)    Recommendations are implemented within one (1) year of being published.

Medical Statement

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

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


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.


Tobacco cessation products require enrollment in the QualChoice Kic the Nic program for most plans.



Effective 12/01/2017:  Updated to include low to moderate dose statin recommendation.

Application to Products

This policy applies to all health plans and products 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) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.