7 OTC Product Categories Completely Covered by Insurance

Did you know that health plans completely cover certain OTC products when patients present a prescription?

Under Affordable Care Act requirements, insurers must cover certain OTC preventive medications at 100% with no co-pays, co-insurance, or deductibles, but only when the patient obtains a prescription.

In addition, health care reform rules effective January 1, 2011, allow distributions from health flexible spending arrangements (FSAs) and health reimbursement arrangements (HRAs) to reimburse the cost of OTC medicines or drugs when they are purchased with a prescription. Eligible prescribed OTC expenses that Aetna FSAs may pay, for example, are OTC acid controllers, anti-diarrheals, cold sore remedies, sleep aids, painkillers, and respiratory treatments, among others.

To get these OTC expenses reimbursed from their employer’s health FSA or HRA, patients need to provide documentation such as a customer receipt issued by a pharmacy that reflects the date of sale and the amount of the charge, along with a copy of the prescription, according to the Internal Revenue Service.

To provide pharmacists with opportunities to add value to patient counseling by informing their patients of these potential medication cost savings, Pharmacy Times reached out to America’s largest health insurers to find out which OTC product categories they cover when the medicines are age-, gender-, and condition-appropriate and prescribed by a licensed health care professional for preventive care purposes.

The 7 OTC product categories where complete coverage overlaps across UnitedHealthcare, Anthem, Aetna, Cigna, and Humana are as follows:

1. Aspirin

All 5 major health insurers cover aspirin use for the prevention of cardiovascular disease for men aged 45 to 79 years and women aged 55 to 79, though Humana and Anthem expand the latter group to include women aged 45 to 79.

Since September 1, 2015, they have also been covering aspirin use for the prevention of preeclampsia during pregnancy in female patients of childbearing ages.

2. Contraceptives

All 5 major health insurers cover certain forms of OTC birth control for women.

Anthem specifics that it covers OTC items like female condoms and spermicides—a benefit that it also applies to those younger than 19 years.

UnitedHealthcare specifies that it covers OTC contraceptive foams, gels, and sponges, as well as the OTC generics of Plan B and Plan B One-Step, and also female condoms.

Cigna says it covers barrier contraception such as vaginal foam and film.

3. Fluoride Supplementation

UnitedHealthcare, Anthem, Aetna, Cigna, and Humana all cover fluoride supplements for the prevention of dental cavities in children, but each has different requirements for 100% coverage.

UnitedHealthcare only specifies coverage for prescription fluoride tablets or solution (not toothpaste or rinses) for children aged 0 to 6 years whose water source is deficient in fluoride.

Anthem specifies OTC fluoride supplements for children from birth through 6 years of age, as well as dental fluoride varnish to prevent tooth decay of primary teeth for children from birth to 5 years of age.

Aetna specifies oral fluoride for children aged 6 months through 5 years, while Cigna specifics fluoride supplementation only for children aged 6 to 12 months.

Finally, Humana specifies OTC fluoride for children aged 6 months to 6 years whose primary water source is deficient in fluoride.

4. Folic Acid Supplementation

All 5 major health insurers cover OTC folic acid supplementation to prevent birth defects in female patients of childbearing ages.

Anthem defines this group as all women aged 55 years or younger, while UnitedHealthcare and Cigna specify coverage for only products containing 400 mcg to 800 mcg of folic acid.

5. Iron Supplementation

Similar to fluoride supplementation, each of the 5 major health insurers has different requirements for 100% coverage of iron supplementation for the prevention of anemia due to iron deficiency in children.

Both UnitedHealthcare and Anthem cover iron supplements for children aged 0 to 12 months, though UnitedHealthcare specifies coverage for iron liquid supplements.

Meanwhile, Cigna, Aetna, and Humana cover the supplements for children aged 6 to 12 months, with the latter 2 insurers specifying coverage for children at increased risk for anemia.

6. Smoking Cessation Aids

All 5 major health insurers cover FDA-approved OTC tobacco cessation medications for those 18 years or older.

UnitedHealthcare specifies that in order for patients to qualify for the 100% coverage, their prescriber must let the insurer know that they are also getting counseling to quit tobacco. It also requires prior authorization for OTC nicotine replacement gum, lozenges, and patches.

7. Vitamin D Supplementation

UnitedHealthcare, Anthem, Aetna, Cigna, and Humana all cover vitamin D supplements for the prevention of falls in men and women 65 years or older.

Humana specifies that patients must live in a residential care setting to qualify for the 100% coverage.

Additional OTC Product Coverage

Of note, Aetna covers the following preventive supplies for pregnant women:

• Non—hospital-grade electric breast-feeding pumps anytime during pregnancy or once every 3 years while breast-feeding
• Manual breast pumps anytime during pregnancy or after delivery for the duration of breast-feeding
• Breast pump supplies if patients get pregnant again before they are eligible for a new pump

In addition, Anthem covers OTC colonoscopy prep kits when they are prescribed for preventive colon screening.

Click “Continue reading” to download each major health insurer’s information resources about OTC product coverage.

UnitedHealthcare

Anthem

AetnaCignaHumana