Prescription Drug Coverage

Private Health Coverage

Private health coverage pays for part of your medical costs. These costs can include seeing doctors, having medical tests done, and getting medications. You get private health coverage either by paying a monthly premium directly to an insurance company or by enrolling in a group plan sponsored by your employer or your spouse’s or parent's employer. If you get an individual plan on MNsure, the government may also help pay a portion of your premium.

The details of what medical expenses your private health coverage will pay for depend on how your plan is set up. Different private health coverage plans will pay different amounts for different services in different situations. This means that when you go to the doctor, the hospital, or a pharmacy, your private health coverage will pay part or all of the cost of these services, depending on your plan.

Common private health coverage prescription drug rules

Every health coverage plan is different, but there are a few general rules that can help you figure out what medications your private health coverage will help you pay for and how much you will have to pay out of your own pocket when you get medications.

While we’ll explain a few of the most common rules here, you will have to check with your health coverage provider or your employer’s Human Resources department to get the details of how they work in your plan:

  • Most health coverage plans will not pay for every medication that your doctor may prescribe for you. Formularies are a list of drugs that your health coverage plan will pay for. If you get a prescription for a medication that is not on your formulary, your health plan won’t pay for it. To learn what is in your formulary, you need to speak with your plan manager.
  • Most health coverage plans require you to pay a copayment every time you get a medication. That means that while the health coverage pays for most of the expense of the medication, you have to pay a certain amount each time you get a prescription filled. Usually, generic medications require a lower copayment than brand-name medications. For example, you may have to pay $10 every time you get a generic medication, but $30 every time you get a brand-name medication.
  • Some health plans have deductibles. If your plan has a deductible, you will have to pay the entire cost of any medical charges until you have spent a certain amount. For example, each year you may have to pay the first $2,000 in medical expenses before your health coverage plan will help you pay for medical expenses, including prescription drugs. Some plans may have a deductible for brand-name medications, but not for generic medications.

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 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. Note: There is no income limit for getting subsidies that help pay individual coverage premiums. (Before 2021, the limit was 400% of FPG.) To get subsidies, you still must meet other eligibility rules and the premium amount you pay depends on your income and your plan.

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

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