CurrentHealthPartnersPolicy N/A

Enhanced HSA Preventive Drug List (Coverage Criteria)

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Defines which medications are covered as preventive drugs for members in employer-offered HSA-eligible high deductible health plans, describing that listed drugs may be purchased with a copay rather than applied to the deductible; applies to HealthPartners members with such plans.

Policy Summary

PayerHealthPartners

PolicyEnhanced HSA Preventive Drug List (Coverage Criteria)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Last ReviewJan 1, 2026

Next Review DateN/A

Key ActionCheck member plan details or contact Member Services to confirm eligibility for the HSA preventive benefit and verify any prior authorization or quantity limits noted.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

01/01/2026

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CurrentHealthPartnersPolicy N/A

Enhanced HSA Preventive Drug List (Coverage Criteria)

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Sign up for all HealthPartners policy alerts

Know when HealthPartners releases new policies or updates existing guidance.

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Policy Summary

PayerHealthPartners

PolicyEnhanced HSA Preventive Drug List (Coverage Criteria)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Last ReviewJan 1, 2026

Next Review DateN/A

Key ActionCheck member plan details or contact Member Services to confirm eligibility for the HSA preventive benefit and verify any prior authorization or quantity limits noted.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

01/01/2026

Document last updated

multispecialtyTherapeutic classes

100+Formulary SKUs listed

PA/QL presentRules noted

HSA Preventive Coverage Criteria

Covered as preventive under HSA-eligible plans when plan terms apply.

HSA Preventive Eligibility: Member is enrolled in an employer-offered high deductible health plan intended to be paired with a Health Savings Account (HSA)

Check member's plan details or Member Services to confirm eligibility

Drug inclusion: Medication is listed on the Enhanced HSA Preventive Drug List (a subset of the HealthPartners formulary)

List is reviewed periodically and subject to change; review the most current list before filling prescriptions

Coverage rules: Any applicable formulary rules (e.g., prior authorization, quantity limits) must be met as noted in the 'More Details' column or on the Pharmacy Drug List (Formulary)

Failure to meet PA/QL may result in denial or non-preventive coverage; see Pharmacy Drug List for complete rules

This list identifies medications that may be covered as preventive drugs for members enrolled in employer-offered, HSA-eligible high deductible health plans. Coverage as a preventive benefit depends on plan terms: if there is any discrepancy between the general information here and a member's plan documents, the member's plan documents govern coverage. Check the Pharmacy Drug List (Formulary) and the 'More Details' column for any applicable coverage rules such as prior authorization or quantity limits.

No explicit exclusions are listed in these source excerpts. The document does, however, include an "Unclassified" section that lists nicotine polacrilex formulations (2 mg and 4 mg lozenges), which are presented on the preventive list rather than as an exclusion.

Device and Supply Coding

Device / supply itemsmixed

NOVOTWIST NEEDLE 32G 5MM	listed device/supply
SYRINGE WITH NEEDLE	listed device/supply

Device / supply itemsmixed

NOVOTWIST NEEDLE 32G 5MM	listed device/supply
SYRINGE WITH NEEDLE	listed device/supply

Provider Actions, Prior Authorization & Quantity Limits

Prior Authorization

Prior authorization may be required

Some products listed on the Enhanced HSA Preventive Drug List include “MORE DETAILS = PA” in the More Details column; these items will require meeting the plan’s prior authorization requirements before they are covered as preventive under HSA-eligible plans.

Billing Rule

Prior authorization / quantity notes

The formulary rows enumerate devices, supplies, and medications and mark certain items with 'QL' (quantity limit) or other More Details flags; specific prior authorization codes are not listed here — see the Pharmacy Drug List (Formulary) for complete rules.

Device and supply listings (meters, lancets, pen needles) show More Details flags per row.

Definitions and Terminology

Preventive drug (context)

DefinitionMedications used to help avoid disease and maintain health that may be purchased with a copay under certain HSA-eligible high deductible health plans.

Plan applicationApplies when member is enrolled in an employer-offered high deductible health plan intended to be paired with a Health Savings Account (HSA); check member's plan documents for eligibility details.

List source and maintenanceThe preventive drug list is a subset of the HealthPartners formulary, developed per federal guidance and reviewed periodically.

Coverage impactIf there is a difference between this general information and a member's plan documents, the plan documents determine coverage.

QL — Quantity limit indicator

Meaning of QL

Step Therapy and Authorization Rules

Product / class	More details
liraglutide (0.6 mg/0.1 mL pen injector)	PA, QL
MOUNJARO (various pen strengths: 2.5 mg/0.5 mL; 5 mg/0.5 mL; 7.5 mg/0.5 mL; 10 mg/0.5 mL; 12.5 mg/0.5 mL; 15 mg/0.5 mL)	PA, QL
OZEMPIC (0.25–0.5 mg/dose pen; 1 mg/dose [4 mg/3 mL]; 2 mg/dose [8 mg/3 mL])	PA, QL
RYBELSUS (3 mg, 7 mg, 14 mg tablets)	PA, QL
TRULICITY (0.75 mg/0.5 mL; 1.5 mg/0.5 mL; 3 mg/0.5 mL; 4.5 mg/0.5 mL pens)	PA, QL
GLYXAMBI (10 mg/25 mg tablets)	QL
JARDIANCE (10 mg, 25 mg tablets)	QL
SYNJARDY (various strengths: 5/1,000; 5/500; 12.5/1,000; 12.5/500 mg)	QL
SYNJARDY XR (various strengths: 5/1,000; 10/1,000; 12.5/1,000; 25/1,000 mg)	QL
TRIJARDY XR (various strengths: 5/2.5/1,000; 10/5/1,000; 12.5/2.5/1,000; 25/5/1,000 mg)	QL

Quantity Limits and Affected Products

Various (see More Details) — Quantity limits

ScopeQuantity limits are indicated as 'QL' for various listed products across therapeutic classes (examples include ELIQUIS, XARELTO, TRADJENTA, GLP-1 and SGLT2 products).

Examples — anticoagulants and antidiabeticsELIQUIS, XARELTO, dabigatran, TRADJENTA, liraglutide, MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY — several entries note MORE DETAILS = QL.

Where to find specificsThe More Details column or the Pharmacy Drug List (Formulary) defines the exact numeric limits and any accompanying requirements (e.g., PA).

Accu-Chek Guide and related test strips/monitor — quantity limits

Products with QLACCU-CHEK AVIVA PLUS METER; ACCU-CHEK GUIDE ME GLUCOSE MTR; ACCU-CHEK GUIDE MONITOR SYSTEM; ACCU-CHEK GUIDE L1-L2 control solutions are listed with MORE DETAILS = QL for select items.

Device category

Background

Preventive drugs are intended to help avoid disease and maintain health. The Enhanced HSA Preventive Drug List is a subset of the HealthPartners formulary developed in accordance with federal guidance and is reviewed periodically. When a member's employer offers an HSA-eligible high deductible plan, medications on this list may be purchased for a copay rather than applied to the plan deductible, subject to the member's plan terms and any formulary rules noted on the Pharmacy Drug List.

Policy Summary

PayerHealthPartners

PolicyEnhanced HSA Preventive Drug List (Coverage Criteria)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Last ReviewJan 1, 2026

Next Review DateN/A

Key ActionCheck member plan details or contact Member Services to confirm eligibility for the HSA preventive benefit and verify any prior authorization or quantity limits noted.

SourceLink

On This Page

Test strips and meter systems are frequently marked with 'QL' in the More Details column.

Prior Authorization

Insulin prior authorization

Several insulin products in the list include 'MORE DETAILS = PA', indicating prior authorization is required for those insulin formulations before coverage as preventive.

LEVEMIR 100 UNIT/ML VIAL — MORE DETAILS = PA
LEVEMIR FLEXPEN 100 UNIT/ML — MORE DETAILS = PA
insulin aspart (pens/cartridges/vials) — MORE DETAILS = PA

Step Therapy

Quantity limits / formulary rules

Multiple combination products and specialty agents are labeled with 'QL' or other restrictions in the More Details column; quantity limits and formulary restrictions apply and step therapy requirements are referenced on the Pharmacy Drug List.

GLP-1 and SGLT2 combination products (e.g., MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY) are shown with PA and QL.
Direct factor Xa inhibitors and certain oral anticoagulants have QL or PA flags.

Note

Formulary listing — check More Details

This section of the formulary is primarily a listing of covered products and strengths; it does not itself enumerate explicit PA criteria or denial triggers — check the Pharmacy Drug List and More Details for authorization requirements.

Note

Review product-level More Details

Additional product-specific notes (including More Details flags) appear alongside many entries; providers should review the More Details entry for each product to determine if PA, QL, or other restrictions apply.

Documentation Required

Verify member plan eligibility

Confirm member eligibility for the HSA preventive benefit by checking the member’s plan documents or contacting Member Services prior to prescribing or billing preventive medications.

If plan documents differ from this list, the plan documents determine coverage.
Member Services can confirm whether the member’s HDHP is HSA-eligible and whether the preventive benefit applies.

Billing Rule

Device and supply listing notes

Meters, test strips, lancets, pen needles and other supplies are listed with 'MORE DETAILS' and some items are marked 'QL' — verify the More Details entry for device-specific coverage limits and any required prior authorization.

ACCU‑CHEK AVIVA PLUS METER — MORE DETAILS = QL
ACCU‑CHEK GUIDE MONITOR SYSTEM — MORE DETAILS = QL
Multiple pen needles and lancets listed with More Details flags

Documentation Required

Documentation pointers for insulin products

Insulin and related entries frequently include 'MORE DETAILS' or 'MORE DETAILS = PA', which implies additional documentation or an authorization process is required as defined in the Pharmacy Drug List or prior authorization policy.

See Pharmacy Drug List for required supporting documentation and PA forms for insulin products flagged with PA.

Denial Risk

Coverage rule triggers — authorization required where noted

Coverage is subject to applicable formulary rules; some medications require prior authorization or other coverage rules that must be met before the medication is covered as preventive.

Failure to meet PA/QL requirements may result in denial or non-preventive coverage.

Note

No explicit PA/denial triggers in listing — consult Formulary

This portion of the document is a formulary listing and does not show explicit PA/denial triggers for many items; always consult the Pharmacy Drug List (Formulary) and the More Details column for product-specific authorization requirements.

Prior Authorization

Product-level PA notes present in More Details

Multiple insulin product entries include 'MORE DETAILS = PA' in the product row, indicating that prior authorization may be required for those specific insulin items before coverage is provided.

Examples: LEVEMIR (vial and FlexPen) and insulin aspart are flagged with PA in the More Details column.

'QL' is the quantity limit indicator shown in the More Details column for select diabetes test strips and meter system entries.

Where it appearsExamples include ACCU-CHEK AVIVA PLUS METER, ACCU-CHEK GUIDE ME GLUCOSE MTR, and ACCU-CHEK GUIDE MONITOR SYSTEM listed with MORE DETAILS = QL.

Provider actionQuantity limits noted as QL must be observed; refer to More Details or Pharmacy Drug List for the specific limit and any authorization implications.

These QL notations apply to meter systems, test strips, and related control/solution products used for diabetes self-monitoring.

Action for providersWhen QL is shown for a device or supply, check the More Details entry or Pharmacy Drug List for the allowed quantity and any prior authorization requirements before prescribing or dispensing.