Zero Copayments for Certain Statin Prescriptions
Some statin prescriptions with certain dosage strengths are covered by OptumRx with a zero copayment. If you take a statin medication and wish to know if you qualify for the zero copay, you or your physician should contact OptumRx member services at 1-855-546-3439 to begin the prior authorization process.
Note that lovastatin (Mevacor) does not need a prior authorization to qualify for the zero copay. Please see the details in the statement released by OptumRx, below. Also note that if you do not seek prior authorization for a statin prescription you are currently taking, it will continue to be covered at the current copayment tier.
Affordable Care Act Coverage Update
The U.S. Preventive Services Task Force now recommends low- to moderate-dose intensity statins be provided for primary prevention of cardiovascular disease in individuals at high risk. As a result, the Affordable Care Act requires that statins be covered at $0 cost-share for members who meet all of the following coverage criteria:
- Being age 40 to 75.
- Having one or more cardiovascular risk factors, such as dyslipidemia, diabetes, hypertension or smoking.
- Having a calculated 10-year risk of a cardiovascular event of 10% or greater. This will require universal lipid screening for this age group.
Since the ACA allows medical management, not all statins will be covered at zero cost-share; coverage is summarized in the table below. Prior authorization will be required (with exception of lovastatin) to ensure members are using the medication for primary prevention and have the noted risk factors.
For members who do not go through prior authorization, statins will continue to be covered at a current tier.
Statins Covered at $0 Cost-Share
| Medication | Prior Authorization Status |
|---|---|
| Atorvastatin (generic Lipitor), 10 mg and 20 mg dosage strengths only. |
Required, to confirm risk of cardiovascular disease |
| Lovastatin (generic Mevacor), all dosage strengths. |
Not required |
| Simvistatin (generic Zocor), 5 mg, 10 mg, 20 mg and 40 mg dosage strengths only. |
Required, to confirm risk of cardiovascular disease |
Prior Authorization Statement
The prior authorization for atorvastatin and simvastatin will not stop payment of a claim at the pharmacy. Members that do not have prior authorization for a $0 copayment will be charged their standard plan copayment for these products.
As these two products are the highest utilized products in the class and not all members taking these medications will meet the ACA requirement for $0 coverage, the prior authorization checks the requirements are met prior to waiving the copay for applicable members. A member or their physician can request to have the prior authorization process started through member services.
Lovastatin will be provided at no cost automatically to members between ages 40 and 75. Utilization of lovastatin is low, and lower in cost, than atorvastatin or simvastatin. Lovastatin is included in many $4 drug lists at many pharmacies.