ACA Prevention Copay Waiver Criteria
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Defines clinical criteria under which preventive services and related agents qualify for copay waivers per ACA/HRSA/USPSTF/ACIP recommendations for members whose benefits include ACA Preventive Care.
No material clinical or coverage changes in this revision.
Coverage Criteria for ACA Preventive Services
Aspirin ACA Prevention Copay Waiver Criteria
Covered when ALL of the following are met:
Bowel Prep Agents ACA Prevention Copay Waiver Criteria
Covered when ALL of the following are met:
Length of Approval: 9 months
Breast Cancer Primary Prevention Agent ACA Copay Waiver Criteria
Covered when ALL of the following are met:
Length of Approval: 12 months
Contraceptives ACA Prevention Copay Waiver Criteria
Covered when ALL of the following are met:
Fluoride Supplement ACA Prevention Copay Waiver Criteria
Covered when ALL of the following are met:
Folic Acid ACA Prevention Copay Waiver Criteria
Covered when ALL of the following are met:
Folic acid supplement — approval conditions
Covered when ALL of the following are met:
Length of Approval: 12 months
HIV PrEP — Covered when ALL of the following are met
Covered when ALL of the following are met:
Length of Approval: 12 months
Infant eye ointment — Covered when ALL of the following are met
Covered when ALL of the following are met:
Length of Approval: 3 months
Infant iron supplement — Covered when ALL of the following are met
Covered when ALL of the following are met:
Length of Approval: 3 months
Statins (primary prevention) — Covered when ALL of the following are met
Covered when ALL of the following are met:
Length of Approval: 12 months
Vaccines — Covered when ALL of the following are met
Covered when ALL of the following are met:
Length of Approval: 12 months
Tobacco cessation agents — Covered when ALL of the following are met
Covered when ALL of the following are met:
Implicit exclusions apply when a request does not meet the policy’s foundational coverage conditions. Specifically, any request where the member's benefit does not include ACA Preventive Care for the relevant category, or where the agent, indication, age, strength, or other module-specific criteria are not satisfied, is considered excluded from approval under these copay waiver criteria. Examples in the criteria sets include age limits, required agent strengths, specified indications (e.g., primary prevention, PrEP, gonococcal prophylaxis), and dose ranges that must be met for approval.
Requests will be denied when the member's benefits do not include ACA Preventive Care for the requested category. Every individual criteria set requires verification that the member’s plan includes ACA preventive coverage for that specific category (for example, vaccines, statins for primary prevention, PrEP, infant supplements). If that benefit is absent, the request is excluded from consideration for the copay waiver.
A core requirement across all copay waiver modules is that the requested agent be medically necessary. Requests where the agent is not medically necessary do not qualify for approval under these criteria. Providers must document clinical justification that the agent is indicated for the member’s preventive need and meets the module-specific elements (for example, correct strength, indication, age range, or pregnancy support).
Statin requests for primary prevention will not be approved under the copay waiver if the specified clinical thresholds are not met. Approval requires the patient to be aged 40–75 years (inclusive), to have at least one listed risk factor (dyslipidemia, diabetes, hypertension, or smoking), and to have a calculated 10-year ASCVD risk of >= 10% per the ACC/AHA ASCVD calculator. Requests failing any of these conditions (age outside 40–75, absence of a qualifying risk factor, or a 10-year ASCVD risk <10%) are considered not medically necessary for the purposes of the copay waiver and may be denied.
Key Values, Age Limits, and Risk Thresholds
Prior Authorization, Documentation, and Denial Risks
Prior authorization required; approval only if all criteria met
Prior authorization/approval is required when applying the copay waiver to preventive agents or services; approval is granted only when all module-specific criteria are met and the member's benefit includes ACA Preventive Care for the category requested.
Prior authorization for ACA preventive agents
Prior authorization is required for ACA preventive agents and requests will be evaluated against the listed ACA preventive criteria for each agent (see the respective module-specific criteria).
Reserved
Reserved.
Reserved
Reserved.
Document medical necessity and module-specific criteria
Providers must document medical necessity and that the request meets the module-specific criteria (for example, agent strength, indication, age limits) and confirm that the member's benefit includes ACA Preventive Care for the category requested.
Documentation to include benefit and indication-specific details
Documentation must include confirmation that the member's benefit includes ACA Preventive Care, the medical necessity of the requested agent, indication-specific criteria (e.g., age or risk status, recent HIV negative test for PrEP, folic acid dose and pregnancy support), and the intended duration of use.
Denial triggers: benefit exclusion or lack of medical necessity
Requests may be denied if the member's benefit does not include ACA Preventive Care for the category requested or if the agent is not medically necessary or does not meet specified age, strength, or indication criteria.
Denial risk if benefit lacks ACA Preventive Care
There is a denial risk when the member's benefit does not include ACA Preventive Care for the requested category; such requests are excluded from approval.
Denial risk for statins if age, risk factors, or ASCVD threshold not met
Statin requests risk denial if the patient is outside the 40–75 year inclusive age range, lacks at least one listed risk factor (dyslipidemia, diabetes, hypertension, or smoking), or has a calculated 10‑year ASCVD risk below 10% per the ACC/AHA ASCVD calculator.
- Age requirement: 40–75 years (inclusive)
- Must have ≥1 risk factor: dyslipidemia, diabetes, hypertension, or smoking
- Calculated 10‑year ASCVD risk ≥ 10% required
Scope and Guideline Alignment
This policy aligns copay-waiver eligibility with major preventive guidance sources. Criteria and coverage decisions reference recommendations from the U.S. Preventive Services Task Force (USPSTF), the Health Resources & Services Administration (HRSA), the Advisory Committee on Immunization Practices (ACIP)/CDC, and the Bright Futures guidance where applicable. For statin determinations the policy uses the ACC/AHA ASCVD calculator to estimate 10-year cardiovascular risk and requires the inputs typical for that tool (sex, age, race, HDL, total cholesterol, blood pressure, diabetes status, hypertension treatment, and smoking status) when establishing the 10-year ASCVD risk threshold of >= 10% for approval.
Definitions and Calculators
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