News & Updates
The federal government released a series of FAQs in January 2014 requiring non-grandfathered health insurance coverage offered in the individual or group market to cover certain medications that reduce the risk of primary breast cancer without cost-share.
The benefit applies to women who meet certain criteria and is subject to reasonable medical management. This requirement is effective for plan or policy years beginning on or after September 24, 2014, and is based on the U.S. Preventive Services Task Force (USPSTF) B recommendation issued in September 2013.
The USPSTF recommends that clinicians engage in shared, informed decision-making about medication options with women who are at increased risk for breast cancer. The USPSTF also recommends that clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene, to women at increased risk for breast cancer but are low risk for adverse medication effects.
In response to the USPSTF recommendation, effective September 24, 2014 (all in and not upon a plan’s renewal), UnitedHealthcare will cover tamoxifen and raloxifene when prescribed to reduce the risk of breast cancer as a preventive benefit. The benefit is available for women:
UnitedHealthcare estimates that fewer than 5% of the women currently taking these medications would qualify to receive these drugs without cost-share.
A new Preventive Care Medication list reflects theses updates.
Today, UnitedHealthcare covers these risk-reducing breast cancer drugs both when prescribed for other indications or to reduce the risk of breast cancer, and in these cases, cost-sharing may apply.
Prior Authorization Needed
To receive coverage for the medications as a preventive benefit without cost-share, a woman must meet the criteria and must obtain a prior authorization review to determine appropriate cost-share. Prior authorization is needed because these drugs may also be prescribed for other indications, and in these cases, cost-sharing will continue to apply.
When a UnitedHealthcare member visits the pharmacy, a point-of-sale message informs the pharmacist that prior authorization is needed to determine if the member is eligible before zero cost-share is applied.
Prior authorization currently does not apply when tamoxifen, and raloxifene are prescribed for other indications.
Plans Not Impacted by This Requirement
This preventive benefit does not apply to:
A customer is responsible for understanding how their plans are filed whether they are exempt or grandfathered.
Grandfathered and exempt plans will keep cost-share when these medications are prescribed for either prevention or treatment.
For more information:
For questions, please contact a member of your b&p Sales Team - 888.722.3373.