Preventive care medications (no-cost share list)
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This document lists medications and products that Hometown Health covers at no cost share under the ACA preventive services requirement and describes eligibility and how members obtain them. It affects members whose plans follow this preventive care medications list and network pharmacies/providers filling prescriptions.
No material clinical or coverage changes in this revision.
Coverage Criteria for Preventive Medications
General preventive medication coverage
Covered when ALL of the following are met
Applies to USPSTF A & B medications, FDA‑approved contraceptives, vaccines and other listed preventive products.
Tobacco cessation
Tobacco cessation medications covered at $0 when ALL are met
Step therapy: prescription medications (e.g., varenicline, bupropion SR) are covered after the member has tried one OTC nicotine product and bupropion SR separately.
HIV pre-exposure prophylaxis (PrEP)
HIV PrEP medications covered at $0 when ALL are met
Specific listed PrEP drugs (e.g., emtricitabine‑tenofovir disoproxil fumarate [generic Truvada], tenofovir disoproxil fumarate, Apretude ER, Descovy) are available at $0 cost share when criteria are met.
Breast cancer preventive medications
Breast cancer preventive medications covered at $0 when ALL are met
Drugs listed include anastrozole, exemestane, and raloxifene; most plans continue normal cost share for these drugs when used for treatment or other indications.
Statin preventive medications
Statin therapy for primary prevention is covered at $0 when ALL are met
Select statin products (eg, atorvastatin, pravastatin, rosuvastatin, simvastatin) are listed; copay waiver review may be required per drug/plan.
Standard preventive medications and vaccines
Covered when ALL of the following are met:
Some items (eg, breast cancer risk drugs, select statins, or colonoscopy preparations not on the list) may require provider submission of a Health Care Reform copay waiver review form to obtain $0 cost share.
Members should verify specific drug availability and benefit details via the current Optum Rx drug list or by calling the number on the member ID card.
Products must be filled at a network pharmacy to be covered at no cost. If a member obtains a listed preventive medication or product from an out-of-network pharmacy, they may have to pay the full cost rather than receiving $0 cost share.
The document excerpt in this section is primarily a product listing of contraceptive generics and their branded "sold as" names and does not state explicit coverage exclusions. Coverage details follow the general eligibility rules that the product be prescribed, age- and condition-appropriate, and filled at a network pharmacy.
Some long-acting reversible contraceptives, such as IUDs and implants (for example, Kyleena, Liletta, Mirena, Nexplanon, Paragard, Skyla), may be covered under the medical benefit rather than the pharmacy benefit. Verify benefit routing because billing to the incorrect benefit may result in improper processing or denial.
Certain employer-sponsored plans may be exempt from covering contraceptives if the employer has elected a religious or moral exemption. In those cases Optum Rx may provide or arrange separate contraceptive coverage as allowed by the health reform law; providers and members should confirm plan-specific coverage.
No explicit additional exclusions are listed in this excerpt. Availability of the no-cost preventive medications is limited to network retail pharmacies, and for most medications also to Optum Home Delivery when the member's plan includes that benefit (for example, a 3-month supply can be mailed with no cost for standard shipping).
Age Thresholds and Key Eligibility Values
Provider Actions, Prior Auth, and Billing Notes
Submit Health Care Reform copay waiver review to request $0 cost share
A Health Care Reform copay waiver review form (submitted by the member's doctor) is required to request $0 cost share for breast cancer primary prevention drugs and to confirm eligibility for select statin preventive coverage.
- Provider must submit the Health Care Reform copay waiver review form when requesting $0 cost share for breast cancer preventive medications.
- Select statins require copay waiver review to confirm cardiovascular risk before $0 cost share is granted.
No prior authorization specified for listed oral contraceptives
This section lists generic-to-brand mappings for many oral contraceptive products but does not state any prior authorization requirement for those listed contraceptives.
- No prior authorization instructions or codes are specified for the listed oral contraceptives in these entries.
No prior authorization required (not specified)
The contraceptive product listings do not specify any prior authorization requirements for the products shown.
- No prior authorization steps or forms are referenced in these contraceptive product entries.
Verify medical vs. pharmacy benefit routing for IUDs/implants
Some intrauterine devices (IUDs) and implants may be covered under the medical benefit rather than the pharmacy benefit; providers should verify benefit routing and any medical benefit authorization requirements before billing.
- Billing an IUD or implant to the pharmacy benefit when it should be routed to the medical benefit may result in improper routing or denial.
- Confirm benefit routing with the member's plan or Optum Rx contact on the member ID card.
Use Health Care Reform copay waiver review process for select medications
Certain medications (for example: breast cancer risk‑reducing drugs and some statins) require prior review via the Health Care Reform copay waiver process to obtain $0 cost share; providers should submit the copay waiver review form or call the number on the Optum Rx member ID card for instructions.
- Providers must submit the Health Care Reform copay waiver review form when requesting $0 cost share for breast cancer prevention drugs.
- For select statins and colonoscopy preparations not on the list, call the number on the Optum Rx member ID card for instructions on requesting coverage at no cost.
No prior authorization codes provided — verify plan resources
The document does not list specific prior authorization codes or detailed PA rules; providers should check the Optum Rx drug list and the member's benefit documents for any plan-specific prior authorization requirements.
- Verify current utilization management requirements on optumrx.com or by calling the number on the member ID card.
Step therapy: try OTC nicotine and bupropion SR first for tobacco cessation
For prescription tobacco cessation medications, members must first try one over‑the‑counter nicotine product and bupropion sustained‑release separately before coverage of certain prescription medications is provided.
- Ensure documentation reflects member tried one OTC nicotine product and bupropion SR separately prior to prescribing covered prescription cessation meds.
No step therapy specified in this excerpt
These contraceptive product listings and other excerpts do not describe any step therapy requirements or sequencing.
- If step therapy is a concern, verify plan-specific rules on optumrx.com or by phone.
No fail‑first or step therapy requirements stated
No step therapy or fail‑first requirements are described in the listed product chunks.
- Consult plan-specific Optum Rx resources if utilization management is needed.
Operational reminder: prescribe and confirm network dispensing for $0 coverage
Providers should follow the operational guidance in the list: prescribe covered preventive medications and ensure prescriptions are filled at a network pharmacy or Optum Home Delivery when available to obtain $0 cost share.
- Prescribe the medication and confirm member meets age/condition criteria.
- Advise members to fill prescriptions at a network pharmacy or Optum Home Delivery to avoid out‑of‑network charges.
Brand products may be replaced by FDA‑approved generics
When an FDA‑approved generic equivalent becomes available, prescription brand products may be replaced by the generic.
- Be aware that pharmacies may dispense the generic equivalent once approved.
No step therapy specified — verify plan resources
No step therapy requirements are specified in these excerpts; consult plan-specific Optum Rx resources for utilization management rules if needed.
- Check optumrx.com or call the number on the member ID card for plan‑specific step therapy policies.
Prescription required; submit copay waiver form when applicable
Providers must write a prescription for preventive medications; for certain services (low‑dose aspirin for preeclampsia risk, breast cancer risk‑reducing drugs, select statins) they may also need to submit a Health Care Reform copay waiver review form to request $0 cost share.
- Provide a prescription and document the member meets age and condition criteria.
- Submit the copay waiver review form when required to request $0 cost share.
Offer Optum Home Delivery 3‑month supply option when eligible
For eligible prescriptions (including emergency birth control and other listed items), members may obtain a 3‑month supply via Optum Home Delivery with no cost for standard shipping.
- Advise members that home delivery can provide a 3‑month supply and may reduce pharmacy trips.
- To start home delivery, members should call the number on their Optum Rx member ID card.
No clinical documentation requirements stated in these entries
These product listing chunks contain brand/generic mappings only and do not state clinical documentation requirements for coverage.
- If specific documentation is required for a copay waiver or prior review, the document directs providers to submit the copay waiver form or call Optum Rx.
OTC contraceptives require prescription and network pharmacy dispensing
Over‑the‑counter contraceptives require a prescription and must be obtained from a network pharmacy for Optum Rx to cover the costs at no charge.
- Ensure the member has a prescription for OTC contraceptives and directs them to a network pharmacy for dispensing.
Provide prescription and submit copay waiver review form for select preventive services
Providers must provide a prescription and, when applicable (e.g., low‑dose aspirin for preeclampsia risk, breast cancer prevention, select statins), may need to submit a Health Care Reform copay waiver review form to request $0 cost share.
- Include clinical justification and confirm age/condition criteria when submitting copay waiver review forms.
Verify current drug list and member benefits before prescribing
Providers and members should verify the current Optum Rx drug list and benefit details by logging in to optumrx.com or calling the number on the Optum Rx member ID card before prescribing or filling a preventive medication.
- Checking the current drug list avoids unexpected coverage differences when the formulary changes.
Network pharmacy requirement — out‑of‑network fills may not be $0
Filling preventive medications at an out‑of‑network pharmacy may result in the member paying the full cost; ensure prescriptions are filled at a network pharmacy or Optum Home Delivery when available.
- Confirm the member's preferred pharmacy is in‑network to avoid denials or out‑of‑pocket charges.
No denial triggers specified in these excerpts
No explicit denial triggers are listed in these product listing excerpts.
- If coverage denial is suspected, contact Optum Rx or review the member's benefit plan for details.
No PA or denial triggers in product listing
This section is a product listing and does not specify prior authorization or denial triggers for the listed contraceptive products.
- Confirm utilization management requirements elsewhere if needed.
Benefit routing risk: confirm billing pathway for IUDs and implants
Billing the wrong benefit (pharmacy vs medical) for long‑acting reversible contraceptives like IUDs or implants may lead to improper routing or denial; verify whether the item should be billed to the medical benefit.
- If the device is covered under the medical benefit, follow medical benefit authorization and billing procedures.
Call Optum Rx if preventive colonoscopy prep is not on the list to request $0 coverage
If a colonoscopy preparation medication prescribed for a preventive colonoscopy is not on the listed medications, the member or provider must call the number on the Optum Rx member ID card to request coverage at no cost; otherwise the prescription may not be covered at $0 cost.
- Consider prescribing a listed preparation when clinically appropriate to ensure $0 coverage, or follow Optum Rx instructions for review if an unlisted product is needed.
Coverage risk if drug list currency is not verified
Drug lists can change; failure to check the current Optum Rx drug list may result in unexpected coverage differences if the drug list has been updated.
- Verify formulary status before prescribing to avoid surprises for the member.
Background and Policy Scope
This preventive medication list implements the health reform requirement to cover certain medications and products at no cost when they meet USPSTF A & B recommendations or are FDA-approved preventive therapies. To receive $0 cost share the product must be prescribed by a health care professional, be age- and condition-appropriate, and be filled at a network pharmacy. The list includes FDA-approved contraceptives, vaccines, tobacco cessation and HIV PrEP drugs, select statins, breast cancer risk–reducing medications, and other preventive products; members and providers should check the current drug list for specific items and any required copay waiver review processes.
Definitions and Key Terms
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