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Coverage criteria policies

Statin medications for prevention of cardiovascular disease

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 HealthPartners Pharmacy Administration for preferred low-to-moderate dose statin medications prescribed for the prevention of cardiovascular disease for coverage as a Preventive Benefit.

The prior authorization form is available here. Required information includes:

  1. Provider attestation that the member has no history of cardiovascular disease (CVD), and
  2. Member has one or more CVD risk factors, and
  3. Member has a 10-year risk of a cardiovascular event of 10% or greater, per the ACC/AHA risk calculator.

Coverage

Preferred low-to-moderate dose statin medications for the prevention of cardiovascular disease are generally covered as a Preventive Benefit according to the indications listed below and per your plan documents.

Members to whom this recommendation applies

Preferred low-to-moderate dose statin medications for the prevention of CVD events and mortality are covered as a Preventive Benefit for adults ages 40 to 75 years when all of the following criteria are met:

  1. Members with no history of CVD (i.e., symptomatic coronary artery disease or ischemic stroke), and
  2. One or more CVD risk factors (i.e., dyslipidemia, diabetes, hypertension, or smoking), and
  3. A calculated 10-year risk of a cardiovascular event of 10% or greater.

Indications that are not covered

  1. Statin medications are covered per standard pharmacy benefit for adults who do not meet the above criteria.

Definitions

Statins are a class of medication that inhibit the HMG-CoA reductase enzyme, limiting the production of cholesterol. These statin medications are low-to-moderate dose statins per the United States Preventive Services Task Force (USPSTF). The formulary status is described in the Drug Formulary. These medications are covered as a Preventive Benefit when criteria are met.

Low- and Moderate-Dose Statin Regimens

Low-Dose Statins

Moderate-Dose Statins

Fluvastatin 20 to 40 mg

Lovastatin 20 mg

Pitavastatin 1 mg

Pravastatin 10 to 20 mg

Simvastatin 10 mg

Atorvastatin 10 to 20 mg

Fluvastatin 40 mg BID

Fluvastatin XL 80 mg

Lovastatin 40 mg

Pitavastatin 2 to 4 mg
Pravastatin 40 to 80 mg
Rosuvastatin 5 to 10 mg
Simvastatin 20 to 40 mg

Cardiovascular Disease (CVD): is caused by cholesterol deposits in the heart and blood vessels, and can lead to a heart attack or stroke.

United States Preventive Services Task Force (USPSTF or Task Force): an independent group of national experts in prevention and evidence-based medicine that works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services.

Preventive Benefit: Services covered as preventive services are derived from the Patient Protection and Affordable Care Act requirements which include the US Preventive Services Task Force, A and B Recommendations, the Advisory Committee on Immunization Practices (ACIP), and the Health Resources and Services Administration (HRSA) Bright Futures Project and Institute of Medicine committee on women’s clinical preventive services.

Risk factors for CVD. The USPSTF recommends using the ACC/AHA Pooled Cohort Equations to calculate 10-year risk of CVD events. The calculator derived from these equations takes into account age, sex, race, cholesterol levels, systolic blood pressure level, antihypertension treatment, presence of diabetes, and smoking status as risk factors.

The ACC/AHA risk calculator is available at www.cvriskcalculator.com/.

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

  1. US Preventive Services Task Force-Statin Use for the Primary Prevention of CVD in Adults- Preventive Medication 2016

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Policy activity

  • 09/21/2017 - Date of origin
  • 11/01/2017 - Effective date
Review date
  • 11/2017

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