CurrentHealthPartnersPolicy N/A

ACA Preventive Medications List — Coverage Criteria

Defines which medications HealthPartners covers as Affordable Care Act (ACA) preventive medications at no cost for eligible commercial plan members and summarizes limits and coverage rules.

Policy Summary

PayerHealthPartners

PolicyACA Preventive Medications List — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain a prescription and ensure medications are filled at an in-network pharmacy; check the formulary for any prior authorization or step therapy requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

zerocopay for eligible ACA preventive medications

Commercialapplies to

multiplecategories with limits

annuallist reviewed

Coverage Criteria for ACA Preventive Medications

Category-specific coverage limits

Medications in these categories are covered as ACA preventive medications at zero copay for eligible members, subject to the listed limits and coverage rules.

Category limits: Bowel Preparation Agents: Coverage is limited to adults ages >44 or <76 years.

Coverage subject to prescription, in-network pharmacy fill, and any formulary rules such as prior authorization.

Category limits: Breast Cancer Medications: Coverage is limited to women at increased risk of breast cancer ages 35 years or older.

Coverage subject to prescription, in-network pharmacy fill, and any formulary rules such as prior authorization.

Category limits: Fluoride (oral): Coverage is limited to children from 6 months through 16 years.

Coverage subject to prescription, in-network pharmacy fill, and any formulary rules such as prior authorization.

Policy Summary

PayerHealthPartners

PolicyACA Preventive Medications List — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain a prescription and ensure medications are filled at an in-network pharmacy; check the formulary for any prior authorization or step therapy requirements.

SourceLink

On This Page

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Provider Actions and Requirements

Prior Authorization

Prior Authorization May Be Required

Some medications listed on the formulary require prior authorization before they are covered. Please verify prior authorization requirements on the Pharmacy Drug List (Formulary) and submit required documentation with the prior authorization request to avoid delays or denials.

Check the Pharmacy Drug List (Formulary) for which products require prior authorization
Include clinical documentation and indication when submitting prior authorization

Step Therapy

Step Therapy May Apply

Step therapy rules may apply to certain drug classes. Members may be required to try specific first‑line medications (steps) before coverage is provided for alternative agents. Confirm step-therapy requirements on the formulary prior to prescribing.

Review step-therapy edits on the Pharmacy Drug List (Formulary)
Document prior trials of required step agents when requesting an exception

Documentation Required

Prescription and Pharmacy Requirements

A valid prescription is required for coverage of all medications listed as ACA preventive medications, including over‑the‑counter (OTC) products. Medications must be dispensed through an in-network pharmacy or approved vendor to be covered.

Prescription required for OTC preventive medications to qualify for zero copay
Medications must be filled at an in-network pharmacy or approved vendor

Note

Coverage Rules and Prior Authorization

Coverage rules and any prerequisite requirements (age limits, risk criteria, prior authorization, step therapy, quantity limits) must be met before a medication will be covered. Refer to the Pharmacy Drug List (Formulary) for complete, up-to-date coverage rules; this list is reviewed at least annually and is subject to change.

Coverage may be limited by age or clinical criteria for specific preventive medication categories (e.g., bowel prep, fluoride, smoking cessation, statins, HIV prevention, breast cancer meds)
Confirm member eligibility and formulary rules before dispensing to avoid claim denials

Step	Requirement
1
Check the Pharmacy Drug List (Formulary) for any step therapy requirements that may apply; coverage rules may apply and are not fully shown here.

Definitions

inv-08: ACA preventive medications — definition and criteria (USPSTF A/B, ACIP, HRSA).

DefinitionACA preventive medications: medications covered without copayment, coinsurance, or deductible when recommended by USPSTF (A/B), ACIP, or HRSA pediatric/women's guidelines.

Coverage stanceMedications in listed categories are covered as ACA preventive medications at zero copay for eligible commercial plan members.

Prescription & pharmacy requirementA prescription is required for all medications (including OTC) for coverage and medications must be filled at an in‑network pharmacy.

Prior authorization & formulary rulesCoverage rules such as prior authorization or other formulary requirements may apply; check the Pharmacy Drug List (Formulary) for complete coverage rules.

Review frequencyThis list will be reviewed at least annually and is subject to change at any time.

Plan document precedenceIf plan documents differ from this general information, the specific plan documents determine coverage.

Background

Under the ACA, certain preventive medications recommended by guideline bodies are covered without member cost-sharing. HealthPartners maintains a list of medications designated as ACA preventive medications and covers those medications at a zero copay for eligible commercial plan members in accordance with essential health benefit recommendations. Coverage is subject to the age or population limits specified for each medication category and to any formulary rules (for example, prior authorization) and dispensing requirements described below.

Providers should note key program requirements: a prescription is required for all medications, including over-the-counter products, for coverage as an ACA preventive medication, and the medication must be filled at an in-network pharmacy. Some medications may have additional coverage rules such as prior authorization, so the Pharmacy Drug List (Formulary) should be consulted for complete coverage rules. The list is reviewed at least annually and may change at any time.

OpenPayer

ACA Preventive Medications List — Coverage Criteria

Coverage Criteria for ACA Preventive Medications

Provider Actions and Requirements

Step Therapy Requirements

Definitions

Background