How can I get prescription benefits from private health coverage?

Your private health coverage will help you pay for your prescription drugs. If you don’t have private health coverage right now, these are the most common ways to get it:

  1. Private health coverage is often offered as part of your compensation for work. You may also get it through a spouse's or parent's job. This employer-sponsored coverage varies greatly in terms of how much it will cost you and the extent of prescription coverage it includes.
  2. Individual health coverage can be purchased for you and your family at MNsure. If your family's income is at or below 400% of the Federal Poverty Guidelines ($48,560 per year if you're single; $100,400 for a family of four) and you can't get employer-sponsored coverage and don't qualify for Medicare, Medical Assistance, or MinnesotaCare, the government may help you pay your monthly premium through tax subsidies.

For more details, read DB101’s articles on Employer-Sponsored Health Coverage and Buying Individual Health Coverage on MNsure.

How much will my prescriptions cost if I am on Medical Assistance (MA)?

Most MA enrollees pay a small copayment for their prescription drugs:

  • $3 for brand name drugs
  • $1 for generic drugs

The maximum MA enrollees have to spend on prescription drug copayments in a single month is $12. There is no copayment on some mental health drugs.

If you’re under 21, pregnant, or in a long-term care facility, you won’t have to pay a copayment for your prescription drugs.

If you are eligible for Medicare, MA will not pay for your prescription drugs, except for benzodiazepines, barbiturates, and a few others.

What is Medicare Part D?

Medicare Part D, also known as Medicare Prescription Drug Coverage or MedicareRx, provides prescription drug coverage for people on Medicare. In the Part D program, private companies offer Prescription Drug Coverage plans to people on Medicare. Each plan has a list of drugs that they will help pay for if you sign up with their plan. This list is called a formulary.

Unless you qualify for Medicare's Low Income Subsidy, you will generally have to pay a premium, a certain amount you pay each month to be on the plan; a deductible, a certain amount you pay before the plan will help you pay for your drugs; and some of the rest of the costs of your drugs, called “co-pays” or “coinsurance”. These amounts change January 1 of each year. If you pay these costs, the plan will help pay for your prescription drugs when you buy drugs that are on the plan’s formulary.

For more information on Medicare Part D, read DB101’s section on Medicare.

How does Medical Assistance (MA) prescription drug coverage interact with Medicare Part D?

You will automatically be enrolled in a Medicare Part D benchmark plan if you haven't already signed up for a plan on your own and are also:

  • On disability-based MA without a spenddown
  • On MA with a spenddown and have met your spenddown, or
  • On MA-EPD

Being enrolled in disability-based MA or MA-EPD and Medicare automatically qualifies you for the Part D Low Income Subsidy. This means you won’t have to pay a premium for your Part D or any deductibles, including the donut hole. All you would pay for your prescription drugs is a copayment of $1.25 – $3.40 for generics or $3.80 – $8.50 for brand name prescriptions. If you are on MA with a spenddown, once you meet your spenddown for one month in the year, you automatically qualify for the Low Income Subsidy for the entire year, and you’re automatically enrolled in a benchmark plan, if you have not already signed up for a plan on your own and otherwise qualify for automatic enrollment.

How can I find a Medicare Part D plan that covers my prescriptions?

There are many variations among Part D plans, so it is important to find one that works for your needs. Two resources that can help you choose a plan that covers the medications you need are:

What prescription drug benefits are offered by MA-EPD?

MA-EPD prescription benefits are the same as those for Medical Assistance (MA). With MA-EPD, prescription drugs require only a:

  • $3 copayment for brand name drugs
  • $1 copayment for generic drugs

The maximum copayment total for prescription drugs for one month is $12. There is no copayment on some mental health prescription drugs.

If you are enrolled in both MA-EPD and Medicare, you are eligible for Medicare Part D prescription drug coverage with no Part D premium and no Part D deductibles. You pay only a $1.25 – $8.50 copayment for prescription drugs.

What are Patient Assistance Programs (PAPs)?

Drug companies offer Patient Assistance Programs (PAPs) to provide free or discounted prescription drug coverage to uninsured and underinsured people. These include Medicare and Medical Assistance (MA) beneficiaries and those who have private health insurance but do not have adequate prescription drug coverage.

Eligibility requirements for individual PAPs vary widely, so be sure to check the requirements for each program before applying.

Are there any medical eligibility requirements for PAPs?

Depending upon the PAP, medical eligibility requirements may require you to have a specific diagnosis. However, many PAPs do not. Be sure to check with each PAP for specific medical eligibility requirements.

How do I find a PAP that meets my needs?

PhRMA and its member companies launched the Partnership for Prescription Assistance - a directory of all Patient Assistance Programs (PAPs) and the prescriptions that are covered. Partnership for Prescription Assistance directs individuals to appropriate PAPs.

RxAssist has a database of Patient Assistance Programs, with up-to-date information on nearly 700 medications and on how to get help from nearly 100 companies.

What is the AIDS Drug Assistance Program (ADAP)?

The AIDS Drug Assistance Program (ADAP) provides HIV/AIDS related prescription drugs to uninsured and underinsured individuals living with HIV/AIDS.

If you qualify, ADAP may pay for some or all of the cost of HIV/AIDS related medications that other insurance does not cover.

Who is eligible for ADAP?

To get ADAP in Minnesota, residents must meet the following eligibility guidelines:

  • HIV positive
  • Below 300% Federal Poverty Guidelines
  • Currently uninsured or insured with a drug co-pay
  • Not on Medicare, Medical Assistance, Medical Assistance for Employed Persons with Disabilities, or MinnesotaCare.

What drugs does ADAP cover?

The ADAP Drug Formulary is the list of medications ADAP pays for. Minnesota’s formulary includes all primary HIV treatment drugs, Opportunistic Infection (OI) drugs and a number of side effect drugs. Minnesota’s ADAP Drug Formulary has an advisory committee of HIV specialty physicians, pharmacists, case managers and consumers, who meet regularly to discuss issues and make recommendations.

For a list of specific medications in the Minnesota ADAP Drug Formulary, click here.