Currentblue cross blue shield - michiganPolicy N/A

Preventive Drug Coverage (PDF)

Policy Summary

Payerblue cross blue shield - michigan

PolicyPreventive Drug Coverage (PDF)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionA prescription from a doctor is required for preventive care drugs or products covered under the pharmacy plan, including over-the-counter drugs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this update.

MultipleCovered Indications

PV1/PV2/PV3PV1/PV2/PV3 listings for $0 cost when ACA criteria met

Age-limitedAge-based constraints

Coverage Summary

Lists drugs and products covered as preventive services under the Affordable Care Act by Blue Cross Blue Shield of Michigan / Blue Care Network, including vaccines, contraceptives, smoking cessation, cancer prevention agents, bowel preparations for colorectal screening, statins for cardiovascular prevention, PrEP, aspirin for preeclampsia prevention, fluoride, and folic acid with associated age/quantity/other coverage notes. Coverage is provided when health care reform (ACA) requirements are met and the product is indicated on BCBSM drug lists as PV1, PV2, or PV3. A prescription from a doctor is required for preventive care drugs or products covered under the pharmacy plan (including some OTC drugs), and members must use network providers. When ACA requirements aren't met, coverage and out-of-pocket costs apply per the member's benefit design.

Coverage Conditions and Criteria

General coverage conditions for preventive drugs/products

Covered when ALL of the following are met:

ALL of the following

Drug/product is listed with PV1, PV2, or PV3 on BCBSM drug lists
Designations on BCBSM drug lists indicating preventive listings eligible for ACA no-cost coverage when requirements are met (PV1/PV2/PV3).
Prescription from a doctor is required for preventive care drugs or products covered under the pharmacy plan, including over-the-counter drugs
Member must use network providers
Health care reform (ACA) preventive requirements are met; otherwise coverage/out-of-pocket costs apply per member's benefit design
When requirements aren't met, either the drug isn't covered, or coverage and applicable out-of-pocket costs apply based on your benefit design.

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General coverage conditions for preventive drugs/products

Vaccines

Vaccines are covered with conditions:

ALL of the following

Vaccine must be on the complete list for each pharmacy benefit drug list at bcbsm.com/druglists
Administered by a pharmacy participating with BCBSM and certified to administer vaccines
Quantity limits may apply
Additional coverage requirements may apply

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Contraceptive and related products

Covered contraceptive products include prescription and OTC items with noted conditions:

Examples listed

Etonogestrel/ethinyl estradiol vaginal ring (EluRyng®, Nuvaring®)
pH modulator (Phexxi®)
Diaphragms (Caya®, Wide-Seal®)
Cervical caps (FemCap®)
Nonoxynol-9 vaginal sponge (Today®)
Nonoxynol-9 vaginal gels and films (Gynol II®, VCF®)

Other preventive products

ANY of the following

Aspirin OTC 81 mg
Generic only; for pregnant members who are at high risk for preeclampsia.
Fluoride drops/tablets 0.25 mg, 0.5 mg, and 1 mg6 months-16 years
Generic only
Folic acid OTC 400 mcg and 800 mcg
Generic only; for members planning or capable of becoming pregnant.

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Provider Actions & Billing Impact

Documentation Required

Prescription required

A prescription from a doctor is required for preventive care drugs or products covered under the pharmacy plan, including over-the-counter drugs.

Billing Rule

Use participating pharmacy and certified vaccine administrator for vaccines

Vaccines must be administered by a pharmacy that participates with Blue Cross Blue Shield of Michigan and is certified to administer vaccines. Quantity limits and additional coverage requirements may apply; see BCBSM vaccine lists and guidance.

Prior Authorization

Coverage per drug list and benefit design

Drugs/products are available with no out-of-pocket costs when health care reform requirements are met and the product is listed as PV1, PV2, or PV3 on BCBSM drug lists. When requirements aren't met, either the drug isn't covered or coverage and applicable out-of-pocket costs apply based on the member's benefit design; prior authorization may be required per plan.

See BCBSM drug lists for PV1/PV2/PV3 listings at bcbsm.com/pharmacy and bcbsm.com/druglists.
Prior authorization may be required per the member's benefit design when health care reform requirements are not met.

Billing Rule

Generic dispensed when available

The generic equivalent will be dispensed where available when filling a prescription.

Denial Risk

Out-of-pocket cost if criteria not met

Out-of-pocket cost may apply if step therapy or other coverage criteria are not met for certain preventive products.

Examples include smoking cessation products where out-of-pocket cost may apply if step therapy criteria is not met.
Breast cancer prevention agents may have out-of-pocket costs if step therapy criteria is not met.
PrEP (Descovy®, Truvada®) may have out-of-pocket cost if coverage criteria isn't met.

Background

Under the Affordable Care Act (national health care reform), most health plans must cover certain preventive services and drugs with no out-of-pocket costs. This document lists representative drugs and products covered by BCBSM that comply with those preventive benefit requirements and notes that those items will have a 'PV1,' 'PV2' or 'PV3' listing on BCBSM drug lists and are available with no out-of-pocket costs when ACA requirements are met.

For current, complete drug lists and coverage requirements, consult bcbsm.com/pharmacy and for vaccine-specific lists consult bcbsm.com/druglists. Additional vaccine information is available at bcbsm.com/vaccines. Use these resources to confirm eligibility, listings, and any additional coverage criteria.

Definitions — PV1 / PV2 / PV3

PV1 / PV2 / PV3 — definitionDesignations on BCBSM drug lists indicating preventive drug/product listings eligible for ACA no-cost coverage when requirements are met.

OpenPayer

Preventive Drug Coverage (PDF)

Coverage Summary

Coverage Conditions and Criteria

Coding

Provider Actions & Billing Impact

Background

Revision History