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    v1.0.28
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsBlue Cross Blue Shield Kansas ACA preventive Cover…
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    Currentblue cross blue shield - kansasPolicy N/A

    ACA Prevention Copay Waiver Criteria - Marketplace, Commercial

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    Defines clinical criteria for approving a copay waiver for ACA-preventive pharmaceutical agents (breast cancer primary prevention agents, contraceptives, HIV PrEP, and statins) for BCBSKS marketplace and commercial members; applies to pharmacy benefit or coverage-exception approvals.

    Policy Summary
    Payerblue cross blue shield - kansas
    PolicyACA Prevention Copay Waiver Criteria - Marketplace, Commercial
    Policy CodePolicy N/A
    Change TypeAdded contraceptivesroutine review
    Effective DateAug 1, 2024
    Last ReviewNov 20, 2024
    Next Review DateNov 20, 2024
    Key ActionObtain prior authorization and document medical necessity and member benefit verification for the requested preventive agent.
    SourceLink
    POLICY UPDATE CHANGES

    Contraceptives were added to the policy.

    Policy reviewed and updated with statement that policy statement unchanged.

    4preventive agent modules

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    12 monthsapproval length (contraceptives/PrEP)
    40-75statin age range
    35+breast prevention min age

    Coverage Criteria for ACA Preventive Agents

    Breast Cancer Primary Prevention Agent

    Breast cancer primary prevention agents — Covered when ALL of the following are met:

    Breast cancer prevention approval criteria: 1) The requested breast cancer primary prevention agent is covered under the pharmacy benefit or has been approved through the coverage exception process; 2) There is support that the requested breast cancer primary prevention agent is medically necessary; 3) The requested agent is tamoxifen, raloxifene, or an aromatase inhibitor (anastrozole, exemestane, letrozole); 4) The patient is 35 years of age or over; 5) The agent is requested for the primary prevention of breast cancer; 6) ONE of the following: A) The plan has not implemented a sex requirement; OR B) The plan has implemented a sex requirement AND ONE of the following: (1) The patient's sex is female; OR (2) The requested agent is medically appropriate for the patient's sex.

    Includes sex requirement logic nested under condition 6

    Contraceptives

    Contraceptive agents — Covered when ALL of the following are met:

    Contraceptive approval criteria: 1) The requested contraceptive agent is covered under the pharmacy benefit or has been approved through the coverage exception process; 2) The requested agent is being used for contraception; 3) There is support that the requested contraceptive agent is medically necessary.

    Length of approval: 12 months

    HIV PrEP

    HIV pre-exposure prophylaxis (PrEP) — Covered when ALL of the following are met:

    PrEP approval criteria: 1) The requested PrEP agent is covered under the pharmacy benefit or has been approved through the coverage exception process; 2) The requested agent is being used for PrEP; 3) There is support that the requested PrEP agent is medically necessary; 4) The requested PrEP agent is one of the following: tenofovir disoproxil fumarate + emtricitabine OR tenofovir alafenamide + emtricitabine; 5) The patient has increased risk for HIV infection; 6) The patient has recently tested negative for HIV.

    Length of approval: 12 months

    Statin Primary Prevention

    Statin for primary prevention of cardiovascular disease — Covered when ALL of the following are met:

    Statin approval criteria: 1) The requested agent is a generic statin (MSC=Y) unless a generic statin is not available for the requested agent; 2) The requested statin is covered under the pharmacy benefit or has been approved through the coverage exception process; 3) There is support that the requested statin is medically necessary; 4) The requested statin is for use in the primary prevention of cardiovascular disease; 5) The patient is 40-75 years of age (inclusive); 6) The patient has at least one of the following risk factors: dyslipidemia, diabetes, hypertension, smoking; 7) The patient has a calculated 10-year ASCVD risk of 10% or greater per the ACC/AHA ASCVD calculator.ASCVD >= 10%

    ASCVD risk must be calculated per ACC/AHA calculator

    State and federal mandates and a member's contract language, including any specific provisions or exclusions, take precedence over this Medical Policy when determining eligibility for coverage. Verify benefits and contract provisions in effect at the time of service to determine coverage or non‑coverage for an individual member.

    Determinations that a requested preventive agent is medically necessary must be supported by documentation that meets the clinical criteria in this policy and by the member's benefit contract. Providers should verify that the agent is covered under the pharmacy benefit or has been approved via the coverage‑exception process and retain clinical evidence showing the indication and necessity for the requested agent.

    Key Values and Definitions

    ASCVD 10-year risk threshold used for statin criteria
    ASCVD 10-year risk threshold>= 10%
    Calculator sourceAmerican College of Cardiology/American Heart Association ASCVD Risk Estimator
    Required inputsSex, age, race, HDL, total cholesterol, blood pressure, diabetes status, hypertension treatment, smoking status
    Minimum age for breast cancer primary prevention agent
    Minimum age>= 35 years
    Applicable agentstamoxifen, raloxifene, or an aromatase inhibitor (anastrozole, exemestane, letrozole)
    Indication

    Provider Requirements and Authorization Actions

    Documentation Required

    Benefit verification and medical necessity documentation

    Verify member benefits and document the medical necessity and coverage pathway before submitting requests. Confirm whether the requested preventive agent is covered under the pharmacy benefit or requires approval through the coverage exception or prior authorization processes. Include documentation of clinical rationale and any evidence supporting medical necessity in the request.

    • Verify member contract benefits at time of service with BCBSKS Customer Service
    • Document clinical justification and relevant diagnostic or risk-calculation results (e.g., ASCVD 10-year risk for statins, HIV test result for PrEP, indication for contraceptive use)
    • If the agent is not covered under the pharmacy benefit, obtain approval through the coverage exception process
    Prior Authorization

    Prior Authorization Required

    Prior authorization is required when the preventive agent must be approved through the coverage exception or pharmacy benefit prior authorization process. Requests lacking evidence of coverage pathway or necessary documentation may be denied.

    Initial Authorization and Therapy Rules

    Initial Therapy Rules

    Initial authorization durations and product restrictions:

    Initial durations and product rules: Contraceptives and PrEP: length of approval 12 months; Statins: the requested agent should be a generic statin (MSC=Y) unless no generic is available for the requested agent.

    Use coverage exception when agent is not covered under pharmacy benefit; verify member benefits and document medical necessity.

    Step Therapy and Product Preference

    StepRequirement
    1Generic statin preferred (MSC=Y) unless no generic available for requested agent.

    Policy Background and Rationale

    The Affordable Care Act requires a mechanism to waive cost sharing for an alternative recommended preventive product when a $0‑cost covered product is inappropriate for an individual. This policy uses USPSTF/HRSA‑aligned criteria and the member's benefit provisions to identify appropriate populations for such waivers; final coverage depends on the member's contract and applicable mandates.

    Key Definitions

    ASCVD risk definition referenced for statin criteria
    ASCVD calculation standardUse the ACC/AHA ASCVD Risk Estimator to calculate 10-year risk
    Inputs requiredSex, age, race, HDL, total cholesterol, blood pressure, diabetes status, hypertension treatment, smoking status
    Decision thresholdAuthorize statin when calculated 10-year ASCVD risk >= 10%

    Policy Revision History

    2017-10-01policy_added

    Policy added to the BCBSKS website (original effective date).

    2022-12-13review_no_revision

    Policy reviewed and maintained by Prime Therapeutics with no revisions.

    2024-01-05review_no_revision

    Policy reviewed and maintained by Prime Therapeutics with no revisions.

    Policy Summary
    Payerblue cross blue shield - kansas
    PolicyACA Prevention Copay Waiver Criteria - Marketplace, Commercial
    Policy CodePolicy N/A
    Change TypeAdded contraceptivesroutine review
    Effective DateAug 1, 2024
    Last ReviewNov 20, 2024
    Next Review DateNov 20, 2024
    Key ActionObtain prior authorization and document medical necessity and member benefit verification for the requested preventive agent.
    SourceLink
    On This Page
    Coverage Criteria for ACA Preventive AgentsKey Values and DefinitionsProvider Requirements and Authorization ActionsInitial Authorization and Therapy RulesStep Therapy and Product PreferencePolicy Background and RationaleKey DefinitionsPolicy Revision History
    Primary prevention of breast cancer
    Age range for statin primary prevention authorization
    Authorized age range40-75 years (inclusive)
    Requirement linked to indicationStatin use for primary prevention of cardiovascular disease
    Additional risk requirementPatient must have at least one risk factor (dyslipidemia, diabetes, hypertension, smoking) and ASCVD risk >=10%
    ASCVD risk definition — calculation per ACC/AHA ASCVD Risk Estimator
    DefinitionASCVD 10-year risk calculated per the American College of Cardiology/American Heart Association ASCVD Risk Estimator
    Required inputsSex, age, race, HDL cholesterol, total cholesterol, blood pressure, diabetes status, hypertension treatment, smoking status
    PurposeUsed to determine eligibility for statin primary prevention when 10-year risk is >= 10%
    • Prior authorization required when agent not automatically covered under pharmacy benefit
    • Include documentation that the agent is medically necessary and meets the policy criteria for the specific preventive indication
    Billing Rule

    Statin Product Preference

    Generic statins are preferred. A generic statin (MSC=Y) must be requested unless a generic is not available for the specific agent being requested.

    • If a brand-only statin is requested, document why a generic alternative is not appropriate or available
    Denial Risk

    Coverage and Criteria Compliance

    Requests may be denied if the requested preventive agent is not covered under the pharmacy benefit or has not been approved through the coverage exception process, or if required documentation of medical necessity is absent.

    • Denial risk if benefit verification not completed
    • Denial risk if clinical criteria from the applicable preventive category (e.g., statin, PrEP, contraceptive, breast cancer prevention agents) are not met
    2024-07-01material_update

    Contraceptives were added to the policy.

    2024-11-20review_updatedLatest

    Policy reviewed and updated; policy statement unchanged.