If you have a High Deductible Health Plan and a chronic condition like diabetes, asthma, or heart disease, the IRS allows your plan to cover specific medications, tests, and devices before you meet your deductible without costing you your HSA eligibility. This treatment of preventive care for chronic conditions under HSA rules comes from IRS Notice 2019-45, which reclassified certain maintenance care as preventive. The important catch: your plan is permitted to offer this coverage, not required to. Whether you actually get insulin, statins, or an inhaler pre-deductible depends on whether your insurer or employer chose to adopt the expanded list.1Internal Revenue Service. IRS Notice 2019-45 – Additional Preventive Care Benefits Permitted to be Provided by a High Deductible Health Plan Under Section 223
The Nine Conditions and What Your Plan Can Cover
Notice 2019-45 does not open the door to every treatment for every chronic illness. The IRS named a specific set of conditions and, for each, a specific short list of items shown to prevent expensive acute events like heart attacks, strokes, and diabetic emergencies.2Internal Revenue Service. IRS Expands List of Preventive Care for HSA Participants
Diabetes
Diabetes has the longest list. Insulin and other glucose-lowering medications, hemoglobin A1c testing, retinopathy screening, and glucometers all qualify. ACE inhibitors are on the list for diabetes patients because they protect against the cardiovascular and kidney complications the disease commonly causes, and statins qualify for the same reason.
Heart and Cardiovascular Conditions
Congestive heart failure qualifies for ACE inhibitors and beta-blockers. Coronary artery disease qualifies for the same two drug classes. For the broader category of heart disease, the list covers LDL cholesterol testing and statins.
Hypertension
Read this one carefully. Hypertension qualifies only for a blood pressure monitor. The blood pressure medications themselves are not on the list for a hypertension-only diagnosis. ACE inhibitors and beta-blockers appear under congestive heart failure and coronary artery disease, and ACE inhibitors also appear under diabetes, but if high blood pressure is your only diagnosis, the notice does not cover the drugs used to treat it.
Asthma
Peak flow meters and inhaled corticosteroids used as maintenance therapy qualify.
Depression
SSRIs qualify, on the reasoning that consistent treatment prevents psychiatric crises and the secondary physical health problems untreated depression tends to trigger.
Osteoporosis and Osteopenia
Anti-resorptive therapy qualifies, since it prevents fractures.
Liver Disease and Bleeding Disorders
International Normalized Ratio testing, which monitors clotting function, qualifies.
You Have to Have the Diagnosis
The care counts as preventive only when it is prescribed for a person already diagnosed with the associated condition, and only when the purpose is to keep the condition from worsening or triggering something worse.1Internal Revenue Service. IRS Notice 2019-45 – Additional Preventive Care Benefits Permitted to be Provided by a High Deductible Health Plan Under Section 223 A statin taken for general heart-health reasons by someone who has neither diabetes nor diagnosed heart disease does not fall under this guidance. The link between the diagnosis and the medication is what makes the item preventive.
How to Tell If Your Plan Actually Adopted This
Because the IRS made this permissive rather than mandatory, you cannot assume your HDHP covers any of it before the deductible. Two places to look:
Start with your plan’s Summary of Benefits and Coverage. It should list the preventive services covered without cost-sharing. If chronic-condition items are not there, call your plan administrator or insurer and ask directly whether the plan has adopted the expanded preventive care list from IRS Notice 2019-45. That is the specific reference to use.
Adoption has been uneven since 2019. Self-insured employers can add the benefits fairly quickly; fully insured plans move at the insurer’s pace. During open enrollment, this is a question worth asking about any HDHP option you are considering. For someone on daily insulin or managing heart disease with statins and regular blood work, the difference between a plan that covers those items pre-deductible and one that does not can run into hundreds or thousands of dollars a year before insurance starts paying anything.
If Your Plan Didn’t Adopt It
Your chronic-condition medications, tests, and supplies are still qualified medical expenses. You can pay for them with HSA funds tax-free. You just have to pay full price against the deductible until you meet it, either out of pocket or from your HSA balance. Nothing about the notice changes what counts as a qualified medical expense; it only changes what your plan is allowed to pay for before the deductible.
Why This Exists at All
A qualified HDHP generally cannot pay for covered services before you meet the annual deductible. That is the structural trade-off for the lower premiums and HSA eligibility. Section 223(c)(2)(C) of the Internal Revenue Code carves out one exception: preventive care.3Office of the Law Revision Counsel. 26 USC 223 – Health Savings Accounts Traditionally, preventive meant physicals, immunizations, prenatal care, tobacco cessation, and screenings.4Internal Revenue Service. IRS Notice 2004-23 – Preventive Care for Purposes of Section 223 Ongoing treatment for an existing illness was not in that category, which meant a person with diabetes paid full price for insulin every January until the deductible cleared.
The 2019 notice reclassified specific maintenance items as preventive on the logic that keeping someone with diabetes on insulin, or someone with heart failure on a beta-blocker, prevents the kind of acute event the deductible would otherwise force them to risk. Also worth knowing: the IRS explicitly said this guidance does not make the listed items “preventive care required to be provided without cost sharing” under the Affordable Care Act’s Section 2713 rules. Plans may cover them pre-deductible; they are not compelled to cover them for free.
Related Recent Additions
Two other expansions to the pre-deductible preventive category are worth knowing if you are on an HDHP.
In Notice 2024-75, the IRS added over-the-counter oral contraceptives, including emergency contraceptives, and male condoms to the list of items HDHPs may cover without applying the deductible.5Internal Revenue Service. IRS Notice 2024-75 – Preventive Care for Purposes of Qualifying as a High Deductible Health Plan Under Section 223 The same permissive-not-mandatory rule applies.
Separately, the One Big Beautiful Bill Act made permanent a rule that had been renewed on a temporary basis for years: HDHPs can cover telehealth and other remote care services before the deductible without disqualifying you from HSA contributions. This applies to plan years beginning after December 31, 2024. For chronic-condition management that involves regular virtual check-ins, this pairs with the medication and testing coverage under Notice 2019-45.