Prescription medicationUnder the Affordable Care Act, insurers and employers that sponsor non-grandfathered medical plans must cover and pay the full cost of specified preventive services in accordance with recommendations issued by the U.S. Preventive Services Task Force (USPSTF). Enrollees cannot be required to pay any part of the cost of these services through, for example, co-pays, coinsurance, or deductible requirements, if the services are provided by in-network providers (i.e., providers that have an agreement with the employer or insurer to accept a specified amount for covered services). Plans must provide the USPSTF recommended coverage effective as of the first plan or policy year beginning on or after the date the recommendation is issued.

On September 24, 2013, the USPSTF issued a new recommendation that will require non-grandfathered health plans to cover prescribed risk-reducing medications for breast cancer for certain women. The USPSTF recommended that clinicians engage in shared, informed decisionmaking with women who are at increased risk for breast cancer about medications to reduce their risk. For women who are at increased risk for breast cancer and at low risk for adverse medication effects, the USPSTF recommends that clinicians offer to prescribe risk-reducing medications such as tamoxifen or raloxifene. According to the USPSTF report that accompanied the recommendation, randomized, controlled clinical trials reveal that these drugs have the potential to reduce the risk for estrogen receptor (ER)–positive breast cancer. According to the report, important risk factors for breast cancer include increasing age, family history of breast or ovarian cancer (especially among first-degree relatives and onset before age 50 years), history of atypical hyperplasia or other nonmalignant high-risk breast lesions, previous breast biopsy, and extremely dense breast tissue.

The new coverage mandate will become effective as of the first plan or policy year beginning on or after September 24, 2014. Thus, for non-calendar year group health plans, the effective date of this mandate could be as early as September 24, 2014. For calendar year plans, the mandated coverage becomes effective January 1, 2015. Employers should determine whether implementation of the new mandate will require plan amendments. In addition, enrollment communications and SPDs will need to be modified to ensure that employees and their dependents are aware of this new and important preventive service mandate.

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DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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