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Fourth Quarter 2017 and First Quarter 2018 Preventive Changes Announced
August 24, 2017
The U.S. Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices including Bright Futures™, which are part of the Centers of Disease Control and Prevention (CDC), and the Health Resources and Services Administration (HRSA) make recommendations regarding services that should be covered under the Affordable Care Act (ACA).
Based on recent recommendations, we are making several changes to the UnitedHealthcare Commercial Preventive Care Services Coverage Determination Guideline (CDG) for coverage at no cost share. These changes include medications for individuals at risk for cardiovascular disease (CVD), targeted age bands for lead and fluoride screening, and removal of coverage for prostate-specific antigen (PSA) and rubella screening. Please note that Preventive Services at no cost share are not required for grandfathered plans.
Cholesterol Screening and Statins – Change Effective Dec. 1 (May 15 in New York)
The USPSTF recommends that adults without a history of CVD use low- to moderate-dose intensity statins for primary prevention of CVD when certain risk factors are identified. As a result, some statins will become available at $0 cost-share for members who meet all of the following criteria and do not have a history of CVD:
- Are aged 40-75
- Have one or more cardiovascular risk factors, such as dyslipidemia, diabetes, hypertension or smoking
- Have a calculated 10-year risk of a cardiovascular event of 10 percent or greater.
This coverage will become available Dec. 1 for most fully insured and self-funded groups that have standard health reform preventive coverage.
This change was already implemented for fully insured and Non-Employees Retirement Income Security Act of 1974 (non-ERISA) self-funded groups sitused in New York effective May 15 for groups offering UnitedHealthcare’s standard health reform preventive coverage.
Not all statins will be covered at zero cost-share. Prior Authorization will be required (with exception of lovastatin) to ensure that the member is using the medication for primary prevention of CVD and has the noted risk factors. For members who do not go through Prior Authorization, statins will continue to be covered at their current tier.
|Statins To Be Covered At $0 Cost-Share|
|No Prior Authorization Required||Lovastatin (generic Mevacor®) All Strengths|
Prior Authorization Required to Confirm Risk for Cardiovascular Disease (CVD)
Atorvastatin (generic Lipitor®) 10 & 20 mg*
Simvastatin (generic Zocor®) 5, 10, 20 & 40 mg*
*Only these strengths will be available for $0 cost-share.
These statins will be listed as $0 cost-share on myuhc.com® website when available.
Targeted Age Ranges for Lead and Fluoride Screening
Fluoride Varnish: Effective Jan. 1, 2018, coverage for fluoride treatment in a primary setting will change to cover children ages 0 to 5 years. Coverage ends on the child’s sixth birthday. Coverage aligns age limit with Bright Futures and USPSTF recommendations.
Fluoride Oral Supplements: For carve-in pharmacy customers, coverage for oral fluoride supplements has been expanded to cover dependents ages 0 to 16 years. Coverage ends on the adolescent's 17 birthday. Coverage aligns age limit with Bright Futures recommendations.
- Effective Aug. 1, 2017: New York fully insured and non-ERISA self-funded customers
- Effective Feb. 1, 2018: All other states; all funding arrangements
Lead Screening: Effective Jan.1, 2018, coverage for lead screening will change to cover ages prenatal to six years. Coverage ends on the child’s seventh birthday. Coverage will align the benefit age limit with Bright Futures and USPSTF recommendations.
Removal of Coverage Based on USPSTF Recommendations
Effective Jan. 1, 2018, the PSA and rubella screenings will no longer be covered as preventive nor paid at no cost share based on USPSTF recommendations.
|Rubella Screening||Code 86762 with Diagnosis Code Z00.00, Z00.01, Z11.59, Z20.4|
|PSA Screening||G0102, G0103, 84152, 84153, 84154|
For additional information on Preventive Services changes, please review the grid of 2017/2018 Preventive Services Notable CDG Updates or contact your UnitedHealthcare representative.
January 1, 2018 PDL Updates
The following updates will take effect for the OptumRx direct Prescription Drug Lists (PDLs) on January 1, 2018. Learn more
New Sales Automation Management Tool
Check out our new Sales Automation Management (SAM). Learn more
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