Preventive services coverage updates expand breast and cardiovascular disease screening

Based on new recommendations, and to help people lead healthier lives, 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.

3-D Mammography Screening
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, also known as three-dimensional (3-D) mammography, for breast cancer screening and diagnostic testing.

This policy update aligns with recommendations of 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 include CPT code 77063 digital breast tomosynthesis mammography. This change applies to UnitedHealthcare fully insured and self-funded customers that follow UnitedHealthcare's standard preventive coverage. Self-funded customers who choose not to cover 3-D mammography will need to contact their account representative to exclude the procedure from their plan documents.

Coverage for diagnostic will now include three-dimensional mammography as well under the medical benefit.

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

Cholesterol Screening and Statins
The United States Preventive Services Task Force recommends that adults without a history of cardiovascular disease use low- to moderate-dose intensity statins for primary prevention of cardiovascular disease 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 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.

States and Effective Dates

New York: This change will occur for fully insured and Non-ERISA self-funded groups sitused in New York effective May 15, 2017. This will not apply to New York situs grandfathered plans, unless groups have chosen to offer UnitedHealthcare's standard health reform preventive coverage.

Other States: This coverage will become available on Dec. 1, 2017, for most fully insured and self-funded groups that have standard health reform preventive coverage.

Affordable Care Act Covered Statins
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 cardiovascular disease 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.

Member Information

Statins to be covered at $0 cost share

No Authorization Required

Lovastati (generic Mevacor) – All strengths

Prior Authorization required to confirm risk of cardiovascular disease

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