ACA Preventive Care Medications - OpenPayer

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ACA Preventive Care Medications - OpenPayer

No-cost Preventive Medications — Criteria

General eligibility for no-cost preventive medications

Covered when ALL of the following are met:

ALL of the following

Medication/product is listed as an ACA preventive care medication (e.g., USPSTF A & B recommendations, FDA-approved prescription and OTC contraceptives, ACIP recommended vaccines, listed preventive supplements/products)
Medication/product is prescribed by a health care professional (a prescription is required even for OTC products)
Medication/product is age- and condition-appropriate per the recommendation (specific age limits listed for some items)
Medication/product is filled at a network pharmacy (retail or home delivery) or obtained through medical benefit where applicable (e.g., some IUDs/implants)

Breast cancer preventive medications (primary prevention)

Covered at $0 cost share when ALL of the following are met:

ALL of the following

Member is at higher risk for breast cancer but has not had breast cancer
Member is age 35 or olderBreast cancer preventive medication age >= 35 years
Request is for primary prevention of breast cancer
Provider submits a copay waiver review form to request $0 cost share and member meets coverage criteria

Statin preventive medications (primary prevention of CVD)

Covered at $0 cost share when ALL of the following are met:

ALL of the following

Adult without a history of cardiovascular disease (no symptomatic coronary artery disease or stroke)
Age 40-75 yearsStatin age range: 40-75 years
Has one or more cardiovascular risk factors (high cholesterol, diabetes, hypertension, or smoking)
Estimated 10-year risk of a cardiovascular event is 10% or greater>= 10%
10-year CVD risk threshold

Tobacco cessation medications

Covered at $0 cost share when ALL of the following are met:

ALL of the following

Member is age 18 or olderTobacco cessation age >= 18 years
Medication (OTC or prescription) is prescribed by a provider (prescription required even for OTC products)
Prescription is filled at a network pharmacy

Aspirin to prevent preeclampsia (pregnancy)

Covered at $0 cost share when ALL of the following are met:

ALL of the following

Indication is prevention of preeclampsia during pregnancy
Member is age up to 55 yearsAspirin pregnancy age limit <= 55 years
Prescription is provided

Folic acid supplements

Covered at $0 cost share when ALL of the following are met:

ALL of the following

Indication is prevention of birth defects
Dose is 400 or 800 mcg
Dose requirement: 400 or 800 mcg
Prescription is provided

Bowel preparation for colonoscopy (preventive colorectal cancer screening)

Covered at $0 cost share when ALL of the following are met:

ALL of the following

Indication is needed for preventive colon cancer screening
Member age 45-75 yearsBowel prep age range: 45-75 years
Prescription is provided

Fluoride chew tablets/drops

Covered at $0 cost share when ALL of the following are met:

ALL of the following

Indication is to prevent dental cavities when water source is deficient in fluoride
Available for children up to 5 yearsFluoride tablet age limit <= 5 years
Prescription is provided

HIV pre-exposure prophylaxis (PrEP)

Covered at $0 cost share when ALL of the following are met:

ALL of the following

Member at higher risk of becoming infected with HIV but not yet infected
Prescription is provided

Vaccines (ACIP-recommended)

Covered at $0 cost share when ALL of the following are met:

ALL of the following

Vaccine is recommended for routine use by the Advisory Committee on Immunization Practices (ACIP)
Some vaccines may be covered under the medical benefit rather than the pharmacy benefit; member should check benefit plan
Operational note: some vaccines may be covered under medical benefit and availability may vary by participating pharmacy
Available at participating pharmacies (availability may vary); member presents BSWHP member ID card

Women's contraceptive products

Covered at $0 cost share when ALL of the following are met:

ALL of the following

Product is an FDA-approved prescription or OTC contraceptive (includes pills, rings, patches, injections, emergency contraception, vaginal caps/diaphragms)
Prescription is provided (required even for OTC contraceptives)
Filled at network pharmacy or obtained via medical benefit for IUDs/implants

If medically necessary contraceptive not on formulary: Provider may submit a copay waiver request form if a particular contraceptive is determined medically necessary and not identified on the formulary as ACA preventive