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Affordable Care Act Covers Cost of Tamoxifen, Raloxifene for High-Risk Women

Medicines should be covered when given to lower risk of first breast cancer, federal agency says

January 15, 2013

Written By Nicole Katze, MA, Editor and Manager, Publications

Women at high risk of developing breast cancer should now be able to get medicines to help prevent it at no cost, the U.S. Department of Health and Human Services announced.

The two medicines covered in full — tamoxifen and raloxifene (Evista) — work to block the estrogen some breast cancers need to grow.

Background

The Affordable Care Act makes several preventive health services available to insured women for free. These services are medicines, check ups, and diagnostic tests that help keep you well, such as approved birth control, yearly well-woman visits, domestic violence screening, and annual mammograms if you are over the age of 40.

The U.S. Preventive Services Task Force recently reviewed the quality of research on genetic counseling and testing for women at high risk of developing breast cancer. They found the benefits of screening and counseling to be moderate for this group. HHS, the federal agency that provides guidance to health insurance entities, then announced that tamoxifen and raloxifene should be covered under the ACA. Strong evidence showing the two treatments help lower the risk of developing breast cancer among high-risk women guided them.

Who Is Eligible 

Full-cost coverage for women at high risk is available only when these medicines are given as a means of preventing a first breast cancer, not a second primary breast cancer or recurrence.

This means that to qualify you must have no personal history of breast cancer, but be at greater risk than the average woman of developing the disease. Those at high risk:

  • have a known mutation, or error, in a gene linked to the disease, such as BRCA1 or BRCA2
  • have a strong family history of breast or ovarian cancer
  • are of certain ethnic backgrounds, such as Ashkenazi (Eastern or Central European) Jewish descent

You must also have health insurance coverage required to offer these services at no cost. Plans purchased from state health insurance marketplaces/exchanges will cover the medicines in full, as will many others. If you aren’t sure if yours does, call your insurance provider and ask.

What This Means for You 

If you have an increased risk of developing breast cancer but have never been diagnosed, you may now be able to access medicines that help prevent the disease without the added worry of what they will cost.

You may also qualify for free genetic counseling and testing, if you have a strong family history of breast or ovarian cancer. Results can show if you carry a mutation in BRCA1, BRCA2, or another gene linked to greater risk of developing these cancers.

To learn more about the factors associated with breast cancer-related gene mutations, read our Guide to Understanding Genetics and Family Risk Assessment.

If You Had Breast Cancer

The USPSTF recommendations do not discuss appropriate treatments for women who have had BRCA-related cancer, so HHS’s guidance to health insurers does not address your situation. To find out whether your health insurance covers treatment with tamoxifen, please consult your care team.

Living Beyond Breast Cancer recently joined FORCE and other cancer advocates in asking USPSTF to clarify its language to ensure people with a history of BRCA-related cancers receive adequate health insurance coverage for treatments that reduce the risk of a second primary breast cancer. Learn more by reading our letter and signing the petition to USPSTF

Denver, CO  ·  September 13, 2014

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