ACA Preventive Medications — Coverage Criteria (Commercial Plans)
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Defines which medications HealthPartners classifies as ACA preventive medications for Commercial Plans, notes coverage may be subject to plan rules (prior authorization, step therapy, quantity limits), and applies to prescriptions filled at in-network pharmacies.
No material clinical or coverage changes in this revision.
Coverage Criteria
General coverage conditions
Covered as ACA preventive medications when supported by ACA-designated recommendations and subject to plan rules.
List aligns with USPSTF/ACIP/HRSA guidance; plan-level coverage rules (e.g., prior authorization, step therapy, quantity limits) may still apply
Coverage for ACA preventive medications listed in this document is conditional on plan-level rules. Members’ specific plan documents determine final coverage and may impose additional requirements or restrictions (for example, prior authorization, step therapy, or quantity limits). Providers should verify eligibility and coverage in the member’s benefit documents and the Pharmacy Drug List (Formulary) before assuming a medication will be covered as an ACA preventive service.
Some items identified as ACA preventive medications are subject to additional clinical limits or population restrictions. Examples called out in the list include: coverage of certain breast cancer medications limited to women at increased risk, fluoride oral coverage limited to children up to age 6, and HIV prevention agents where Descovy is limited to persons at high risk of HIV acquisition. These limits take precedence alongside plan administration rules and must be met for preventive coverage to apply.
This section does not contain any explicit statements classifying listed items as "not medically necessary." The document instead notes that coverage rules (such as prior authorization, step therapy, and quantity limits) may apply and that member plan documents determine coverage.
Coding and Code Lists
| ACA-PA | Indicator in list that this medication requires prior authorization under ACA preventive coverage rules |
| PA | Prior authorization |
| QL | Quantity limit |
| ST | Step therapy |
| AE | Age edit |
| aspirin 81 mg | multiple manufacturer 81 mg tablet formulations listed (BAYER, ST. JOSEPH, generics) |
| aspirin ec 81 mg | enteric-coated 81 mg tablet formulations listed |
Provider Actions and Administrative Requirements
Prior Authorization Required
Prior authorization may be required for some medications listed below. Certain drugs (including some statins, antineoplastics, antiretrovirals, and specific branded products) are designated with PA or ACA-PA and require prior authorization before they will be covered. Prescribers should verify PA requirements and submit authorization requests as appropriate to avoid delays in patient access.
- Examples: atorvastatin (ACA-PA), anastrozole (ACA-PA), YEZTUGO 300 MG TABLET (PA, QL), DESCOVY (ACA-PA).
- Check the Pharmacy Drug List (Formulary) for drug-specific PA instructions and forms.
Coverage Rules May Trigger Denial
Coverage rules (PA, ST, QL, AE) may trigger claim denials if not met. Before prescribing or dispensing, confirm that any prior authorization, step therapy, quantity limit, or age edit requirements are satisfied; missing requirements can result in claim denial or member cost-share.
- PA = Prior authorization; ST = Step therapy; QL = Quantity limit; AE = Age Edit.
- Review the Pharmacy Drug List (Formulary) for complete coverage rules and any step-therapy requirements.
Quantity Limit / Denial Risk Note
Quantity limits and special handling flags are present for some OTC and contraceptive items. Items marked QL may have quantity limits or require special handling (which can include prior authorization). Examples include certain condoms and nicotine replacement products flagged QL.
- Contraceptive/OTC examples with QL: several Trojan condom SKUs listed as QL; levonorgestrel 1.5 mg tablet marked QL.
- Smoking cessation examples: apo-varenicline products show QL; some nicotine lozenges/gums have PA or QL flags.
Prescription and Network Requirement
Prescription and network requirements for ACA preventive coverage. A prescription is required for all medications (including OTC drugs) to be covered as an ACA preventive medication, and medications must be filled at an in‑network pharmacy to receive preventive zero copay benefits.
- ACA preventive meds are provided at zero copay for eligible members but coverage limits may apply (see plan documentation).
- Check member eligibility and plan documentation; verify pharmacy network status before dispensing.
Background and Rationale
Under the Patient Protection and Affordable Care Act, certain medications recommended by USPSTF (A/B), ACIP, or HRSA guidelines are provided as preventive services. This policy lists medications HealthPartners considers ACA preventive for Commercial Plans and explains that these medications are covered at $0 copay for eligible members when eligibility and any plan-specified administrative conditions are met. A prescription is required for coverage and medications must be filled at an in‑network pharmacy; coverage rules such as prior authorization, step therapy, or quantity limits (QL) may still apply.
Definitions
Initial Therapy Criteria
Step Therapy
| Medication / Drug group | Step therapy (ST) flag / notes |
|---|---|
| Antilipemic agents (statins) — examples listed: atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin | Some statin entries are marked 'ACA-PA' in the list; check formulary for ST requirements (step therapy may apply per plan). |
| Antineoplastic / endocrine agents — examples listed: anastrozole, exemestane, letrozole | Entries show 'ACA-PA' for these agents; review formulary for any ST requirements. |
| Antiretrovirals / HIV agents — examples listed: YEZTUGO 300 mg tablet, DESCOVY 200-25 mg tablet | YEZTUGO noted with PA and QL; DESCOVY noted 'ACA-PA'. Verify formulary for step therapy rules where applicable. |
| Smoking cessation agents — example listed: bupropion SR; varenicline tartrate noted elsewhere | Smoking cessation agents appear on the list; consult the Pharmacy Drug List for any ST requirements. |
| Vaccines — multiple vaccine products (e.g., COMIRNATY, SHINGRIX) listed | Some vaccines have PA or QL designations (SHINGRIX QL); check formulary for ST applicability. |
Quantity Limits and Special Designations
Site of Care
Fill at in-network pharmacy for ACA preventive coverage
Medications must be filled at an in‑network pharmacy to be covered as ACA preventive medications; ensure prescriptions are routed to an in‑network pharmacy to secure ACA preventive benefits.
- In-network fill is a condition of ACA preventive coverage per the policy's general coverage conditions.
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