CurrentHealthPartnersPolicy N/A

ACA Preventive Medications — Coverage Criteria

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Defines which medications HealthPartners classifies as ACA preventive medications for Commercial Plans and outlines coverage expectations (e.g., no cost-sharing) and applicability to members when filled at in-network pharmacies. Affects providers prescribing and dispensing preventive medications to HealthPartners commercial members.

Policy Summary

PayerHealthPartners

PolicyACA Preventive Medications — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Last ReviewApr 1, 2025

Next Review DateN/A

Key ActionProvide a prescription and ensure the medication is filled at an in-network pharmacy and any applicable prior authorization or quantity limits are met.

SourceLink

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CurrentHealthPartnersPolicy N/A

ACA Preventive Medications — Coverage Criteria

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Policy Summary

PayerHealthPartners

PolicyACA Preventive Medications — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Last ReviewApr 1, 2025

Next Review DateN/A

Key ActionProvide a prescription and ensure the medication is filled at an in-network pharmacy and any applicable prior authorization or quantity limits are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

manymedication entries listed (vaccines, contraceptives, statins, antivirals, etc.)

no cost-sharingACA preventive medication benefit when applicable

annuallist review frequency

4/1/2025document revision date shown in window

limits notedspecific limits for some preventive meds

Coverage Criteria for ACA Preventive Medications

Coverage conditions for ACA preventive medications

Covered when ALL of the following are met

ACA preventive coverage conditions: (1) Medication is identified on HealthPartners ACA Preventive Medications List; (2) A prescription is provided (prescription required for all medications, including OTC products); (3) Medication is filled at an in-network pharmacy; (4) Any coverage rules or utilization management (for example, prior authorization, quantity limits, step therapy) applicable to the product are satisfied; (5) The member's specific plan documents do not impose contrary terms.

Derived from HealthPartners statements that ACA preventive medications are listed, prescriptions and in-network fills are required, coverage rules may apply (e.g., PA, QL), and plan documents govern when differences exist.

ACA Preventive Medications — Covered with limits

Covered when member is eligible for ACA preventive benefits and any product-specific limits are met

General coverage: Products listed (including contraceptives, vaccines, aspirin formulations, vitamins, nonhormonal contraceptives, HIV prevention agents, statins where appropriate, and other medications shown) are covered as ACA preventive medications at zero copay for eligible members.member eligible for ACA preventive benefits

See product-specific limits and utilization annotations in the list.

Product-specific limits (examples)

Breast cancer medications: Covered as preventive only for women at increased risk of breast cancer.women at increased risk
See list: 'Breast Cancer Medications, Limits = Coverage is limited to women at increased risk of breast cancer.' (list notes).
Fluoride (oral): Covered as preventive only for children up to age 6.age <= 6 years
See list: 'Fluoride oral, Limits = Coverage is limited to children up to age 6.'
HIV prevention (emtricitabine/tenofovir; Descovy): Emtricitabine/tenofovir (generic Truvada) is covered as an ACA preventive medication; Descovy is covered as an ACA preventive medication only for persons at high risk of HIV acquisition.high risk for HIV acquisition (for Descovy)
See list: 'Emtricitabine/ tenofovir (Truvada generic) is covered... Descovy coverage ... limited to persons at high risk of HIV acquisition.'

If there is a conflict between the general information in this policy and a member’s specific plan documents, the member’s plan documents govern. HealthPartners provides this list as general guidance for ACA preventive medications, but coverage for a given member depends on the terms of their particular commercial plan.

The ACA requires coverage of medications that correspond to USPSTF A/B recommendations, ACIP immunization recommendations, and HRSA‑supported pediatric and women's preventive guidelines; when plan documents differ, follow the member’s plan documents for final coverage determinations.

Coverage as an ACA preventive medication is conditional: members who do not meet the specified product conditions are excluded from zero‑copay preventive coverage for that product. Examples noted in the list include fluoride oral — limited to children up to age 6, Descovy for HIV prevention — limited to persons at high risk of HIV acquisition, and statins — limited to adults without a history of cardiovascular disease and within the recommended age/risk score.

This section does not use explicit 'not medically necessary' language; instead the policy defines limits on preventive coverage for specific medications and populations. Where limits are specified (for example, breast cancer medications limited to women at increased risk), those limits describe when the ACA preventive benefit applies rather than labeling products as 'not medically necessary.'

Coding and Product Listings

Antiretrovirals (select entries)mixedCovered

DESCOVY	DESCOVY (120-15 MG TABLET, 200-25 MG TABLET) — annotated PA
emtricitabine-tenofv 200-300mg	emtricitabine-tenofv 200-300mg

Antilipemic agents (statins)mixedCovered

atorvastatin calcium (10 mg, 20 mg)	HMG-COA REDUCTASE INHIBITORS
lovastatin (20 mg, 40 mg)	HMG-COA REDUCTASE INHIBITORS
pravastatin sodium (10,20,40,80 mg)	HMG-COA REDUCTASE INHIBITORS
rosuvastatin calcium (5 mg,10 mg)	HMG-COA REDUCTASE INHIBITORS
simvastatin (10,20,40 mg)	HMG-COA REDUCTASE INHIBITORS

Miscellaneous antidepressants and antineoplasticsmixedCovered

bupropion hcl sr 150 mg tablet	ANTIDEPRESSANTS, MISCELLANEOUS (tab er - smoking cessation)
anastrozole 1 mg tablet	ANTINEOPLASTIC AGENTS
exemestane 25 mg tablet	ANTINEOPLASTIC AGENTS
letrozole 2.5 mg tablet	ANTINEOPLASTIC AGENTS

Vaccines / immunizationsmixedCovered

ADACEL	TDAP (SYRINGE, VIAL)
BOOSTRIX	TDAP (SYRINGE, VIAL)
DAPTACEL	DTAP VACCINE
INFANRIX	DTAP SYRINGE
GARDASIL 9	HPV vaccine (9 SYRINGE, 9 VIAL)
COMIRNATY	Pfizer COVID vaccine (multiple formulations listed)
MODERNA COVID	Moderna COVID vaccine (multiple formulations listed)
SHINGRIX	Shingles vaccine (components listed)

Smoking cessation agents and contraceptivesmixedCovered

nicotine gum / lozenge	Smoking cessation agents (various brands and strengths listed)
varenicline tartrate (0.5 mg, 1 mg)	Smoking cessation agent (annotated QL)
multiple contraceptive product codes	Extensive list of contraceptives and formulations

Products with quantity limits or special notationmixed

QL	Quantity limit / prior authorization indicator as presented next to specific products

Utilization annotations (QL, AE, PA)

Utilization annotations presentCertain products in the listing are annotated with utilization management indicators such as QL (quantity limit), PA (prior authorization), and AE (adverse event or additional annotation).

Example: PA annotationDESCOVY is listed with the annotation 'PA', indicating prior authorization may be required before coverage as an ACA preventive medication.

Example: QL annotationSome smoking cessation and contraceptive formulations are noted 'QL' (quantity limit) in the formulary listing, which may restrict dispense quantity or require review.

Implication for providersMedications with QL/PA/AE annotations may require prior authorization, quantity-limit exceptions, or documentation to establish eligibility for the preventive benefit.

Provider Actions, Documentation, and Utilization Management

Documentation Required

Provider Actions and Utilization Management

Some medications listed in this document are subject to utilization management controls that may affect coverage and dispensing. Review plan-specific rules (Formulary/Pharmacy Drug List) and the member's benefits before prescribing or dispensing.

Quantity limits noted (QL) — Certain products in this list are annotated with QL indicating quantity limits or other plan controls that may restrict the amount or frequency of dispensing.
Prior authorization (PA) — Some medications are annotated with PA; prior authorization must be obtained and approved before the medication will be covered.
Coverage rules may apply — Coverage may be limited by age, sex, clinical risk criteria, or other eligibility requirements (examples: breast cancer medications limited to women at increased risk; fluoride oral limited to children up to age 6; HIV prevention agents limited to eligible high‑risk individuals; statins limited to adults without cardiovascular disease within recommended age/risk ranges).
Prescription and network pharmacy requirement — A prescription is required for all medications (including OTC drugs) to be covered as an ACA preventive medication, and such medications must be filled at an in‑network pharmacy.
Documentation for eligibility — Providers should document member eligibility for ACA preventive benefits and any qualifying clinical or risk criteria when coverage is limited (for example, documentation of increased breast cancer risk or HIV risk factors for Descovy/Truvada coverage).

Definitions and Scope

Definition — ACA preventive medications

Definition (term)ACA preventive medications

Definition (description)Medications identified by HealthPartners as preventive under the Affordable Care Act that correspond to USPSTF A/B recommendations, ACIP immunization recommendations, or HRSA-supported pediatric and women's preventive guidelines.

Coverage implicationWhen plan rules are met, these medications may be covered without copayment, coinsurance, or deductible as part of essential health benefits.

Definition — ACA preventive medications (zero copay eligibility)

Zero copay applicabilityMedications recommended as preventive services under the ACA may be covered at zero copay for eligible members when plan rules are met and the medication is filled in-network.

Prescription and in-network fill requirement

Background and Legal Basis

The Patient Protection and Affordable Care Act requires coverage of preventive services without copayment, coinsurance, or deductible when they are recommended by the U.S. Preventive Services Task Force (USPSTF) with an A or B rating, by the Advisory Committee on Immunization Practices (ACIP) for immunizations, or when supported by the Health Resources and Services Administration (HRSA) for pediatric and women’s preventive guidelines. HealthPartners identifies certain medications that correspond to these recommendations and offers them as ACA preventive medications when plan rules and member eligibility are met.

Policy Summary

PayerHealthPartners

PolicyACA Preventive Medications — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Last ReviewApr 1, 2025

Next Review DateN/A

Key ActionProvide a prescription and ensure the medication is filled at an in-network pharmacy and any applicable prior authorization or quantity limits are met.

SourceLink

On This Page

Statins: Coverage as an ACA preventive medication is limited to adults without a history of cardiovascular disease who meet recommended age and risk-score criteria.adult age and risk-score per guideline

See list: 'Statins, Limits = Coverage is limited to adults without history of cardiovascular disease, within recommended age range and risk score.'

Age and risk thresholds in coverage limits

Fluoride age limitOral fluoride preventive coverage is limited to children up to age 6.

Statin age/risk criteriaStatin preventive coverage is limited to adults without a history of cardiovascular disease and only within the recommended age range and risk score.

HIV prevention eligibilityDescovy coverage as an ACA preventive medication is limited to persons at high risk of HIV acquisition; emtricitabine/tenofovir (Truvada generic) is covered as an ACA preventive medication.

Breast cancer medication limitationBreast cancer preventive medications are limited to women at increased risk of breast cancer.

Noncompliance risks — Failure to meet coverage rules (e.g., lack of required prior authorization, exceeding quantity limits, inadequate documentation) may result in claim denials or member cost‑sharing.

This list is maintained and may change — The formulary and coverage rules are reviewed at least annually and are subject to change at any time; always verify current rules prior to prescribing or dispensing.

Prior Authorization

Utilization Indicators (PA, QL, AE, etc.)

Examples of utilization indicators appear throughout the drug list to alert providers to additional requirements.

PA annotation example: DESCOVY is annotated 'PA' indicating prior authorization is required.
QL annotation examples: multiple contraceptives, condoms, and selected smoking cessation products are annotated 'QL' indicating quantity limits.
AE/other indicators: Where present, utilization indicators (QL, AE, PA, etc.) imply that quantity limits, prior authorization, or other utilization controls may apply and should be confirmed in the formulary details.

Billing Rule

Provider Actions — Operational Steps

What providers must do to avoid denials or delayed care.

Check the Pharmacy Drug List (Formulary) for complete coverage rules and operational details prior to prescribing.
Obtain prior authorization when a medication is annotated with PA and include all required clinical information with the request.
Ensure prescriptions (including for OTC products intended as ACA preventive medications) are written and the member fills them at an in‑network pharmacy.
Document any member eligibility or qualifying risk criteria when coverage is limited (e.g., risk documentation for breast cancer prevention, HIV risk assessment for PrEP/Descovy).
Monitor quantity limits and submit medical justification when requesting overrides or exceptions.
Be aware that absence of required documentation or failure to follow utilization controls may result in claim denial or member liability for costs.

Denial Risk

Coverage Limitation Risks

Coverage limitation risks and special-case limits to watch for.

Coverage limited to eligible members — Some medications are covered only for members who meet specific eligibility or risk criteria.
Specific examples: Breast cancer prevention meds limited to women at increased risk; Fluoride oral limited to children up to age 6; HIV prevention (e.g., Descovy) limited to persons at high risk of HIV acquisition; Statins limited to adults without history of cardiovascular disease within recommended age and risk score.
Changes and updates — Policy and formulary limits may change; verify current limits at time of prescribing.
Denial risk — Prescriptions that do not meet documented eligibility criteria, lack required PA, or exceed quantity limits are at risk for denial.

A prescription is required for all medications (including OTC drugs) for coverage as an ACA preventive medication, and medications must be filled at an in-network pharmacy.

Plan documents govern when differentIf there is a difference between this general information and a member's plan documents, the plan documents determine coverage specifics.