Preventive service coverage changes include digital mammography and cholesterol statin screening

Based on new recommendations, UnitedHealthcare is making changes to Preventive Services coverage in two areas:

  • Screening for breast cancer
  • Screening and medications for cholesterol to help prevent cardiovascular disease

Coverage for Digital Breast Tomsynthesis (3-D Mammography)

UnitedHealthcare is a strong supporter of women's health initiatives, and as an integral part of its mission to help people live healthier lives, the company is offering an additional mammography option. Effective April 1, UnitedHealthcare began providing coverage for digital breast tomosynthesis, or three-dimensional (3-D) mammography, for breast cancer screening and diagnostic testing.

This policy update aligns with recommendations by the National Comprehensive Cancer Network (NCCN). The NCCN recently changed its recommendations to include 3-D mammography as an alternative to conventional breast cancer screening. NCCN is a not-for-profit alliance of leading cancer centers that sets standards for high-quality cancer care using evidenced-based guidelines. While not one of the Affordable Care Act preventive guideline agencies, NCCN is an additional source that UnitedHealthcare considers when determining coverage.

UnitedHealthcare's Preventive Care Services Coverage Determination Guideline has been updated to pay Current Procedural Terminology® (CPT) code 77063 screening for mammography as preventive at no cost share. This change applies to UnitedHealthcare fully insured and self-funded customers that follow UnitedHealthcare's standard preventive coverage. Self-funded customers who choose to not cover 3-D mammography should contact their UnitedHealthcare representative to expressly exclude it in their plan documents.

Coverage for diagnostic will now include 3-D mammography, as well under the medical benefit.

UnitedHealthcare recommends each woman discuss mammography screening options with her care provider to determine which test best fits her individual needs.

Cholesterol Screening and Statins

The United States Preventive Services Task Force (USPSTF) now recommends initiating low- to moderate-intensity statins for primary prevention of cardiovascular disease in high-risk individuals. As a result, the ACA will require some statins to become available at $0 cost share for members who meet all of the following criteria and do not have a history of cardiovascular disease:

  • Are aged 40-75, and
  • Have one or more cardiovascular risk factors, such as dyslipidemia, diabetes, hypertension or smoking, and
  • Have a calculated 10-year risk of a cardiovascular event of 10 percent or greater.

Timing

  • New York: The state of New York will implement this provision for fully insured and Non-Employee Retirement Income Security Act of 1974 (Non-ERISA) self-funded groups effective May 15. The New York state mandate does not apply to grandfathered plans, unless groups have chosen to offer standard health reform preventive services.
  • Other States: This coverage will become available beginning December 1 for most fully insured and self-funded groups that have standard preventive services.

ACA-Covered Statins
Since the ACA allows medical management, 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 and has the noted risk factors.

Statins to be covered at $0 cost share

No Prior Authorization required

Lovastati (generic Mevacor) – All strengths

Prior Authorization required to confirm risk of CVD

Atorvastatin (generic Lipitor) 10 & 20 mg*
Simvastatin (generic Zocor) 5, 10, 20 & 40mg*
*Only these strengths will be available for $0 cost share

 

For members who do not go through Prior Authorization, statins will continue to be covered at their current tier.

Member Information

Since this is a positive change with additional coverage for members, no member letters campaigns are planned. These statins will be listed as $0 cost share on myuhc.com, when available.

Please contact your UnitedHealthcare representative with any questions.