Currentblue cross blue shield - kansasPolicy N/A

ACA Prevention Copay Waiver Criteria - Marketplace, Commercial

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

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

12 monthsapproval length (contraceptives/PrEP)

40-75statin age range

35+breast prevention min age

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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)

IndicationPrimary 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%

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.

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

OpenPayer

ACA Prevention Copay Waiver Criteria - Marketplace, Commercial

Coverage Criteria for ACA Preventive Agents

Key Values and Definitions

Provider Requirements and Authorization Actions

Initial Authorization and Therapy Rules

Step Therapy and Product Preference

Policy Background and Rationale

Key Definitions

Policy Revision History