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Below is the information I received from Bethany Beauchine, Director of Employee Benefits.
Effective date is 1/1/2018
Here is the documentation we received from OptumRx (if you have any questions, just let me know):
Select Cholesterol-lowering statin drugs will be covered at $0 cost-share under new ACA regulations:
The United States Preventive Services Task Force (USPSTF) now recommends low- to moderate-dose intensity statins be provided for primary prevention of cardiovascular disease (CVD) in individuals at high risk. As a result, the Affordable Care Act (ACA) will require statins to be covered at $0 cost-share for members who meet specific coverage criteria:
Since the ACA allows medical management, not all statins will be covered at zero cost-share and coverage is summarized in the table below. Prior authorization will be required (with the exception of lovastatin) to ensure the member is using the medication for primary prevention and has the noted risk factors. For members who do not go through prior authorization, statins will continue to be covered at a current tier.
- Being age 40-75 and
- Having one or more cardiovascular risk factors such as dyslipidemia, diabetes, hypertension, or smoking, and
- Having a calculated 10-year risk of a cardiovascular event of 10% or greater. This will require universal lipid screening for this age group.
Statins to be covered at $0 cost-share starting Dec. 1
|No Prior Authorization required||lovastatin (generic Mevacor) – All strengths|
|Prior Authorization required to confirm risk of 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.
Editor’s note: Bob Kopasz is Chair of the Michigan SERA Council. He may be reached at P.O. Box 692, Mt. Morris, MI 48458; phone 810/240-8380.