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1+: BRCA Testing & Contraceptive Coverage Effective July 1

Jun 29, 2015

In response to new Affordable Care Act (ACA) guidance, UnitedHealthcare will add coverage described below for plans which currently have health reform preventive coverage. This information will also will be reflected in the July Preventive Care Services Coverage Determination Guidelines (CDG) and Preventive Care Medication Lists. 

BRCA Genetic Testing Benefit Extended to Personal History July 1
On May 11, the Departments of Treasury, Labor and Health and Human Services released frequently asked questions (FAQ) that clarified the implementation of certain preventive care requirements under the ACA. The departments specifically addressed personal history as it relates to routine breast cancer susceptibility gene (BRCA) testing. 

In response to this new guidance, UnitedHealthcare will cover BRCA testing as a preventive benefit for women 18 years of age or older who have a personal history of breast and/or ovarian cancer. Previously, only women with a family history of breast and/or ovarian cancer were covered under the preventive benefit. 

UnitedHealthcare will continue covering BRCA testing for women at risk with a family history of cancer who meet other testing guidelines as provided by benefit plan documents. Prior Authorization requirements for the BRCA test still apply and are currently reflected in the Preventive CDG. 

New Contraceptives to be Covered as a Preventive Benefit July 1
The May 11 Departments of Treasury, Labor and Health and Human Services frequently asked questions (FAQ) also addressed U.S. Food and Drug Administration (FDA)-approved contraceptives and well-woman preventive care for dependents. 

The May 11 FAQ requires coverage of 18 methods of contraception without member cost-share, 13 of which are typically covered under the pharmacy benefit. In order to comply with the FAQ, UHC is implementing updated contraceptive coverage for all fully insured and self-funded clients with health reform preventive medication coverage on July 1, 2015.

UnitedHealthcare will cover additional methods of contraception without member cost-share under its pharmacy benefit preventive services effective July 1, 2015 as described below:  

UnitedHealthcare already covers the five remaining required methods of FDA-approved contraception under the medical benefit without member cost-share.

Cost of New Contraceptive Coverage
For UHC's self-funded clients, they estimate the cost of this new coverage will be $0.14 - $0.20 per member per month (PMPM).* The majority of the cost increase is driven by member cost-share loss on these products, both copay/co-insurance and deductible. In addition to the member cost-share loss, the estimate assumes a 5-10% increase in utilization and price driven by the $0 cost-share requirements. Costs may differ depending on plan demographics, benefit designs and utilization patterns.

*Cost estimates are based on 2014 annual UnitedHealthcare fully insured utilization, and assume a 5-10% increase in costs and utilization after July 1, 2015. 

Low-dose Aspirin for Preeclampsia to be Covered as Preventive Benefit September 1
The U.S. Preventive Services Task Force (USPSTF) issued a B recommendation for the use of low-dose aspirin (81 mg/d) as a preventive medication after 12 weeks of gestation in pregnant women who are at high risk for preeclampsia to reduce the occurrence of preeclampsia, preterm birth and intrauterine growth restriction in women at increased risk for preeclampsia. 

In response, UnitedHealthcare will begin covering low-dose or baby aspirin (81mg) at $0 cost-share to help prevent preeclampsia in pregnant women effective September 1, 2015. Although low-dose aspirin is available Over-The-Counter (OTC), pregnant women at risk for preeclampsia will be able to get this for no cost if:

Preeclampsia affects approximately 6-8% of pregnant women, according to the U.S. Dept. of Health and Human Services and the National Heart, Lung and Blood Institute.1 

Through UHC's health reform coverage, other strengths of aspirin are already available at no cost to members including 81 mg, 162 mg and 325 mg for women ages 55-79 and men ages 45-79 to prevent cardiovascular disease. 

This new benefit will be effective September 1, 2015 for both self-funded and fully insured health plans that follow our Preventive Care Services Coverage Determination Guideline and offer OptumRx pharmacy benefits.

Cost of Aspirin Coverage Negligible
For UHC's self-funded clients, the cost for this benefit is expected to be low. Pregnant women at risk for preeclampsia must get a prescription from their health care provider to receive low-dose aspirin at no cost. Low-dose aspirin is also inexpensive. The cost of this program is expected to be negligible because the average number of pregnant women in the U.S. is approximately 10% of women ages 15-44,2 and only 6-8% of these women are at risk for this condition.1 As a result, approximately 0.8% of women ages 15-44 in the U.S. may develop preeclampsia.

Updated Preventive Care Medication Lists Available for Clients and Members
The new coverage is now listed on the health reform Preventive Care Medication Lists for UHC's standard Prescription Drug Lists (PDLs) and Formulary along with Frequently Asked Questions:

If you have questions about this new health reform coverage, please contact a member of your b&p Sales Team - 888.722.3373.

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