Managed Care Frequently Asked Questions
Prescription Drug Cost Sharing for Certain Chronic Diseases

The law is effective as of January 1, 2025.

This law applies to health plans purchased directly from insurance companies by individuals, such as the plans offered on MNsure. It also applies to fully-insured employer plans in the small group (2-50 employees) and large group (more than 50 employees) markets in Minnesota.  

A fully-insured plan means the employer buys a plan from an HMO or health insurance company. Many larger companies “self-insure” – this means they pay directly for coverage and can decide what is covered; however, most companies that do this work with an insurance company as a “third party administrator” to process claims, and use their provider network. Self-insured plans are regulated by federal laws, not state laws, so this statute doesn’t apply to those plans. These plans could choose to follow this statute if they wanted to, but they are not required to. Check with your human resources office to find out if your employer plan is self-insured or fully-insured. 

Diabetes, asthma, and allergies that require the use of epinephrine auto-injectors (“epi-pen”) are included in chronic diseases under this law. 

Cost-sharing refers to co-payments and coinsurance.

The law specifies syringes, insulin pens, insulin pumps, test strips, glucometers, continuous glucose monitors, epinephrine auto-injectors and asthma inhalers, but also includes and “other medical supply items necessary to effectively and appropriately treat a chronic disease or administer a prescription drug prescribed to treat a chronic disease.” 

It depends on what kind of plan you have. For standard plans (Individual, Small Group, and Large Group), coverage under this statute is not subject to your deductible rules, with two exceptions:

1. If you have a High Deductible Health Plan (HDHP) with a Health Saving Account (HSA), you will need to meet your deductible for drugs and supplies including asthma drugs and epinephrine auto-injectors before applying the cost sharing related to this statute. This is because federal regulations for these plans limit the coverage you can get before you meet your deductible. For HDHP plans with HSA, you will still be able to get insulin at the lower cost-sharing, because federal law has an exception for insulin.  
2. If you have a catastrophic plan, you will need to meet  your deductible before applying the cost sharing related to this statute. This is because federal regulations for these plans limit the coverage you can get before you meet your deductible. There are no federal exceptions for catastrophic plans. 

Prescription drugs prescribed to treat chronic disease will have a cost sharing amount limited to $25 per month for a one-month supply. This is per prescription. If you receive more than one prescription that qualifies as a chronic disease medication, a co-pay up to $25 can be assigned to each medication you receive. If you also received medical supplies associated with a chronic disease medication, you will incur a co-payment up to, but no greater than, $50 per month (total). This is regardless of the number of chronic disease medications your prescribed medical supplies support.

For detail and specifics on exact co-pays related to your medication, you should reach out to your health plan.