Preventive Care Services Update on OTC Drugs, BRCA Testing, Breast Pumps

Under the health reform law, non-grandfathered health plans are required to cover certain preventive care services without cost-sharing as long as these services are provided by network doctors and health care professionals. Based on recent guidance from the federal government.

The Departments of Labor, Health and Human Services, and the Treasury issued a series of FAQs on Feb. 20, 2013, related to preventive care under the Affordable Care Act. The FAQs clarified: 

• The Departments’ stance on covering over-the-counter (OTC) medications and contraceptives when prescribed.
• Routine breast cancer susceptibility gene (BRCA) testing without cost-share.
• That health plans may cover the costs of purchasing instead of renting breast-feeding equipment  without cost-share.  

OTC medications and contraceptives covered without cost-share at point-of-sale starting Nov. 1, 2013
The FAQs state that aspirin and other OTC  items that have an A or B recommendation from the U.S. Preventive Services Task Force (USPSTF) must be covered without cost-sharing only when prescribed by a health care professional. The FAQs also clarify that contraceptive methods that are generally available OTC are only covered without cost-share if the method is both FDA-approved and prescribed for a woman by her health care provider. The Health Resources and Services Administration Guidelines do not include contraception for men.

The OTC drugs include aspirin, folic acid supplements for women, fluoride and iron supplements for children, and vitamin D supplements for older adults. OTC contraceptives for women include female condoms, emergency contraceptives (Next Choice™, Next Choice One-Dose™, Plan B One-Step®), and contraceptive film, foam and gel. The drugs on our revised Preventive Care Medications lists are covered at 100 percent when age- and gender-appropriate, prescribed by a health care professional and filled at a network pharmacy.

Because of these recommendations, customers with our carve-in pharmacy benefit  through OptumRx will cover select OTC contraceptives for women and select OTC drugs without cost-share when prescribed and filled at a network pharmacy. We are implementing a pharmacy point-of-sale solution for these OTC drugs as of Nov. 1, 2013. Mail-order pharmacy prescriptions for plans with a mail-order benefit begins Jan. 1, 2014. 

BRCA testing without cost-share effective Oct, 1, 2013
The Department of Health and Human Services (HHS) requires  both genetic counseling and BRCA testing, if appropriate, for a woman should be covered as a preventive service and without cost-share. 

A woman’s risk of breast or ovarian cancer is greatly increased if she inherits a BRCA gene mutation. The USPSTF issued a draft recommendation in April 2013 that would give a “B” rating to screening women who have family members with breast or ovarian cancer.  The screening identifies a family history that may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA1 orBRCA2).  The rating provides coverage at no cost-share for  genetic counseling to women with a family history, and if appropriate following counseling, BRCA testing. 

UnitedHealthcare’s Preventive Care Services Coverage Determination Guideline  (CDG) currently covers screening and counseling at no cost-share and will cover the BRCA test without cost-share for some women starting Oct. 1, 2013.  The BRCA test as well as screening and counseling will be covered without cost-share for women age 18 years of age and older with a family history of ovarian and/or breast cancer and who do not have a personal history or current diagnosis of ovarian and/or breast cancer. Prior authorization requirements continue to apply.

UnitedHealthcare covers the BRCA genetic counseling and evaluation for BRCA testing today without cost-share as recommended by the current USPSTF recommendation and listed in our CDG.

Breast Pump Rental No Longer Covered as of Jan. 1, 2014
The federal government clarified in the FAQs that health plans may cover the costs of purchasing instead of renting breast-feeding equipment without cost-share. While UnitedHealthcare covers the rental of hospital-grade breast pumps today under the preventive care services benefit, effective Jan. 1, 2014, UnitedHealthcare will only cover the purchase of personal, double-electric breast pumps. 

In addition to the FAQs, studies show that due to the variability in breast pumps, high-quality, personal use double-electric breast pumps are as effective as, or potentially even more effective than, hospital-grade pumps in outpatient settings. Because a double-electric breast pump is portable and more convenient to use, we believe it provides a better experience for the mother and helps encourage breast-feeding. 

Timing of These Updates
The timing of these updates follows our standard approach when agencies recognized by the federal government recommend new preventive care guidelines or guidance. We update our Preventive Care Services Coverage Determination Guidelines as needed throughout the year and not upon a plan’s renewal. This supports the vital role that preventive care plays in helping our members live healthier lives. 

Also, remember that some grandfathered or exempt plans may not cover preventive services at 100 percent, so some plans may cover the preventive services described here with cost-sharing. 

The revised Preventive Care Medications lists are posted on myuhc.com, and the United for Reform Resource Center, and our Preventive Care Services Coverage Determination Guideline will be updated to reflect these changes.