Preventive Breast Cancer Drugs to be covered


The federal government released frequently asked questions (FAQ) in January, requiring non-grandfathered health insurance coverage offered in the individual or group market to cover certain medications that reduce the risk of primary breast cancer without cost-share. This benefit applies to women who meet certain criteria and is subject to reasonable medical management.

This requirement is effective for plan or policy years beginning on or after Sept. 24, 2014, and is based on the U.S. Preventive Services Task Force (USPSTF) “B” recommendation issued in September 2013. The USPSTF recommends that clinicians engage in shared, informed decision-making with women who are at increased risk for breast cancer about medications to reduce their risk.

For women who are at increased risk for breast cancer and at low risk for adverse medication effects, the USPSTF recommends that clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene.

UnitedHealthcare’s Approach
Effective Sept. 24, UnitedHealthcare will cover risk-reducing breast cancer medications, tamoxifen and raloxifene, as a preventive benefit for women who are:

Ø  35 years or older;

Ø  At increased risk for invasive breast cancer after risk assessment and counseling who meet clinical criteria; and

Ø  Who obtain Prior Authorization.

UnitedHealthcare estimates that less than 5 percent of the women currently taking these medications may qualify to receive these drugs without cost-share, so covering these drugs at no cost-share presents a low financial risk. Due to the minimal financial impact and anticipated low utilization of these medications for preventive purposes, UnitedHealthcare adopted an all-in approach to cover tamoxifen and raloxifene without cost-share effective Sept. 24.

Today, UnitedHealthcare covers these risk-reducing breast cancer drugs both when prescribed for other indications or to reduce the risk of breast cancer, and in these cases, cost-sharing may apply.

Prior Authorization Needed
To receive coverage for the medications as a preventive benefit without cost-share, a woman must meet the criteria and must obtain a Prior Authorization review to determine appropriate cost-share. Prior Authorization is needed because these drugs may also be prescribed for other indications, and any cost-sharing will continue to apply.

When a member visits the pharmacy, a point-of-sale message informs the pharmacist that Prior Authorization is needed to determine if the member is eligible before zero cost-share is applied. The Preventive Care Medications Drug List under Related Links is updated to reflect these drugs and the Prior Authorization requirement.