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January 24, 2024BeneCard PBF monitors the industry, as well as government regulations, for areas that may have an influence on prescription benefits and compliance. Our goal is to help our clients continue to exceed their benefit expectations and provide members with a valuable prescription benefit.
The following information provides an explanation of prescription benefit coverage that is mandated under the Affordable Care Act (ACA) and applicable to non-grandfathered plans.
Preventive Drugs
- The following drugs generally must be covered through the prescription benefit plan with no copayment and no member cost-sharing requirement. If generics are available in the drug category, coverage may be set to generics only, and cost-sharing would apply to brand-name drugs. An exceptions process is available in situations where the generic does not work for the member. Members must obtain a valid prescription.
| Drug Category | Preventive Health Services Regulation |
|---|---|
| Contraceptives | Covered for females 10 years of age or older. Abortifacient drugs are excluded. Certain religious employers, and group health coverage with such plans, may be exempt from the requirement to cover contraceptives. |
| Aspirin | Covered between ages 50-59 as of the date of service and presenting with risk factors for heart disease (smoking, high blood pressure, high cholesterol, and diabetes) to help prevent cardiovascular disease and colorectal cancer, or asymptomatic pregnant persons after 12 weeks of gestation who are at high risk for preeclampsia and have no prior adverse events with low-dose aspirin. |
| Bowel Preparation Products | Covered for adults ages 45 years and older as a part of preventive screening colonoscopy procedure. |
| Statins | Covered for adults between the ages of 40-75 with one or more risks of cardiovascular disease, including dyslipidemia, diabetes, hypertension, or smoking. |
| Folic Acid Supplement | Covered as a daily supplement containing 0.4mg-0.8mg of folic acid for all women between 10-55 years of age who are planning or capable of pregnancy. |
| Iron Supplements for Infants | Covered for infants who are between 6-12 months old. |
| Gonorrhea (Newborn Eye Drops) | Covered for newborns who are between 0-7 days old. |
| Fluoride Chemoprevention Supplements | Oral fluoride supplementation covered for children who are 6 months to 6 years of age. |
| Breast Cancer Risk-Reducing Medications Such as Tamoxifen, Raloxifene, and Aromatase Inhibitors | Covered for women who are at increased risk for breast cancer aged 35 years older. |
| Smoking Cessation | Covered with a valid prescription for FDA-approved pharmacotherapy for cessation in adults who use tobacco. |
| HIV Prevention Drugs* | Covered for persons who are at risk of acquiring or transmitting HIV. |
| RSV Treatment / Preventative* | Nirsevimab treatment covered for infants between birth and 8 months. |
* These categories are recommended as brand and generic coverage due to limited medication availability.
Breast Cancer Prevention
- Plans should provide coverage for tamoxifen and raloxifene as well as aromatase inhibitors (arimidex,
aromasin, and letazole) under the preventative care category at a $0 copay if a patient meets clinical
criteria, including:
1. Family history of breast cancer.
2. Results of genetic testing reflect a chance of breast cancer. - For patients who meet one or more of these criteria, the medication will be provided at a $0 copay, using an available generic as the first step of coverage.