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Coverage criteria policies

Medications for risk reduction of primary breast cancer in women

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required from Pharmacy Administration for formulary medications prescribed for risk reduction of primary breast cancer in women that will be covered as a Preventive Benefit. “Risk reduction of primary breast cancer” means prevention of cancer for women with no symptoms and who have never been diagnosed with breast cancer.

Coverage

Formulary medications (tamoxifen or raloxifene) for risk reduction of primary breast cancer in women are generally covered as a Preventive Benefit according to the indications listed below and per your plan documents.

Indications that are covered

The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians engage in shared, informed decision making 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, clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene.

Tamoxifen or raloxifene for risk reduction of primary breast cancer in women to whom this recommendation applies as stated below are generally covered under Preventive Benefits.

Members to whom this recommendation applies

This recommendation applies to women:

  • aged 35 years or older
  • with no prior diagnosis of breast cancer, ductal carcinoma in situ (DCIS), or lobular carcinoma in situ (LCIS)
  • with a prescriber statement of increased risk of breast cancer (The National Cancer Institute has developed a Breast Cancer Risk Assessment tool available at www.cancer.gov/bcrisktool.)
  • with no history of thromboembolic events (deep venous thrombosis, pulmonary embolus, stroke, or transient ischemic attack)

Indications that are not covered by the Preventive Benefit

Formulary tamoxifen or raloxifene products will be covered under the terms of the Pharmacy Benefit for indications other than risk reduction of primary breast cancer, such as recurrence of breast cancer after being diagnosed and treated.

Definitions

Preventive Medications
The selective estrogen receptor modulators tamoxifen and raloxifene have been shown to reduce the incidence of invasive breast cancer in women who are at increased risk for the disease. Tamoxifen has been approved for this use in women age 35 years or older, and raloxifene has been approved for this use in postmenopausal women. The usual daily doses for tamoxifen and raloxifene are 20 mg and 60 mg, respectively, for 5 years.

Primary Breast cancer
For purposes of this policy, primary breast cancer means that a woman has no symptoms of breast cancer and no personal history of being diagnosed with breast cancer.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

Portions of the contents of these coverage criteria are taken directly from the U.S. Preventive Services Task Force website.

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Policy activity

  • 09/18/2014 - Date of origin
  • 09/18/2014 - Effective date
Review date
  • 11/2017

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