People covered by the state’s employee medical plans may need two kinds of prior approvals to get certain care or medications: prior authorization and insurance referrals.
Prior Authorization
Doctors usually ask for this approval. They send the forms and follow the plan’s rules. If you don’t get approval first, your insurance might not pay for the service or medicine.
Blue Cross and Blue Shield of Minnesota: Go to this page on their website. Scroll down to the “See the full lists of prior authorization and notification requirements” section in the column at right:
The medicines on the list are covered through Blue Cross. If you are looking for a medicine that isn't on this list, go to the CVS Caremark website.
HealthPartners: Go to this page on their website. Scroll down to the “Search our coverage criteria” section. To find rules about your coverage:
Note: Many of the pharmacy policies that appear in this search do not apply to coverage through SEGIP. Go to the CVS Caremark website to find details about pharmacy prior authorizations.
CVS Caremark: Go to this page on their website. You will find an A-to-Z listing of medicines.
Insurance Referrals
To see most specialists, you first need permission from your Primary Care Clinic (PCC.) You chose your PCC. You can find it listed as your Primary Care Provider (PCP) on your medical insurance ID card.
Ask your PCC for a medical insurance referral. It's how your insurance pays for care from many other providers.
However, you can go directly to these providers in your HealthPartners or Blue Cross network. Make sure the provider you see is in the network you selected.
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Obstetricians/gynecologists
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Chiropractors for acute care
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Mental health providers
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Substance use disorder providers
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Eye doctors for routine eye exams
Also, you do not need a referral for care you get in an emergency room or at urgent care.
Go to the Official Plan Documents section below and select Summary of Benefits for more details.
Cost Estimate for Dental Treatments
Predetermination and pretreatment estimate of benefits are two other phrases you’ll hear. They are cost estimates from your dental plan. If you need dental work that isn’t just a checkup or cleaning, ask your dentist to get you a cost estimate before you get care. This cost estimate helps you understand:
HealthPartners Dental calls this process a Predetermination. Delta Dental calls it a Pretreatment Estimate of Benefits.
The estimate is just that, an estimate. Go to your HealthPartners Dental or Delta Dental Summary of Benefits to review the rules for coverage.
CVS Caremark oversees prescription drug coverage for all employees and their family members who have the state's medical coverage.
The list of approved medications, called a formulary, assigns and prices medicines in levels. How much you pay depends on the level the medicine is in and quantity. When a doctor prescribes you a medicine on the list, it will generally fall into one of these categories:
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Preferred Generic, Nonpreferred Generic, Formulary Generic: It is the best cost value for most drugs. You pay up to $18 for a 30-day supply.
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Nonformulary Generic: Log into your CVS account. Search by drug name and zip code to get a price.
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Preferred brand and Formulary brand: You pay $30 for a 30-day supply.
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Nonpreferred brand: You pay $55 for a 30-day supply.
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Nonformulary brand: Log into your CVS account. Search by drug name and zip code to get a price.
You also need to know:
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Copays are different for some medications that treat people who have diabetes. Go to the Advantage Value for Diabetes drug list for more details.
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CVS will send you an ID card for your prescription drug coverage. It's the same card whether you have Blue Cross or HealthPartners administering your medical plan.
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The yearly out-of-pocket maximum for prescriptions is $1,050 for single coverage, $2,100 for family.
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When your spending for the year reaches the yearly out-of-pocket maximum for your coverage, your insurance pays all remaining eligible prescription drug expenses for that year.
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Get most prescriptions filled at any pharmacy in the CVS Caremark network. The network includes pharmacies not owned by CVS Caremark.
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You must get specialty drugs through CVS Specialty. Specialty medications usually treat more complex conditions.
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You'll also hear CVS Caremark referred to as the Pharmacy Benefits Manager or PBM.
Note: If you signed up for the Advantage High Deductible Plan, your costs are different. See your plan documents for details on how your prescription drug coverage works.
Learn more about getting the care you need when you visit or live outside Minnesota or the counties that border the state.
Anyone with the Minnesota Advantage Health Plan can get routine care no matter where they visit or live. Just go to a health care provider within your HealthPartners or Blue Cross national network when you're outside the plan's service area. Call the number on the back of your ID card to find the most current providers.
The out-of-area care schedule of benefits outlines how the care is covered. You’ll see that it’s similar to what you’d pay at a cost level 3 primary care clinic in Minnesota. The care you get is considered out of the area if the clinic isn't located in Minnesota or in the Iowa, Wisconsin, North Dakota, or South Dakota counties that border Minnesota. Review the list of border counties that are in area compared to out-of-area.
Emergency care you get at a hospital is covered the same wherever you are and whether the hospital is in your network or not. You have a copay between $100 and $350, depending on your PCC's clinic level. Insurance pays, even if you haven’t met your deductible.
When you go to an urgent care clinic, you pay a copay ($35 to $90) just like you would at your primary care clinic. You pay your full deductible before insurance pays for care. The same rules apply wherever you are in the country. The urgent care clinic does not need to be in your Blue Cross or HealthPartners network.
Note: If you signed up for the Advantage High Deductible Plan, your costs are different. See your plan documents for details on emergency and urgent care coverage.
Official Plan Documents
Summary of Benefits, Schedule of Benefits, rates, and answer to questions for employees who are related.
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Minnesota Advantage Health Plan is the health insurance coverage for state employees, and retirees under age 65 and/or not eligible for Medicare. People enrolled in the plan may also cover their spouse, children, and other dependents who are eligible.
Summary of Benefits - A description of the Minnesota Advantage Health Plan medical and prescription drug coverage.
Summary of Material Modification (SMM) - A summary of changes to the Summary of Benefits effective February 5, 2025.
Summary of Material Modifications (SMM) - A summary of changes to the Summary of Benefits effective July 1, 2025.
Schedule of Benefits - A chart outlining benefits, coverage, and how much you pay when you get care.
Out-of-Area Care Schedule of Benefits - A chart outlining benefits, coverage, and how much you pay when you get care away from Minnesota and the counties that border the state.
Rate Summary - Tables showing how much you pay each month toward your health insurance premium. The amount is based what percent of the premium your employer pays.
FAQ – Related SEGIP Participants - Information for employees who are related and want to be covered under one family policy.
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Advantage High Deductible Health Plan (HDHP) is health insurance that is an option for some employees. Employees who are eligible for this coverage work under the Commissioner’s Plan or Managerial Plan pay agreements. The HDHP is also available to most employees who are not represented by a labor contract or pay plan.
The Minnesota Advantage Health Plan and the HDHP are both options for these employees.
HDHP Plan Documents
Summary of Benefits HDHP - A description of the Advantage High Deductible Health Plan (HDHP) medical and prescription drug coverage.
Summary of Material Modifications (SMM) - A summary of changes to the Summary of Benefits effective February 5, 2025.
Summary of Material Modifications (SMM) - A summary of changes to the Summary of Benefits effective July 1, 2025.
HDHP Schedule of Benefits - A chart outlining benefits, coverage, and how much you pay when you get care.
Out-of-Area Care Schedule of Benefits - A chart outlining benefits, coverage, and how much you pay when you get care away from Minnesota and the counties that border the state.
HDHP Rates - Tables showing how much you pay each month toward your health insurance premium. The amount is based on the percentage of the premium your employer pays.
HDHP FAQ - Frequently asked questions about the Advantage High Deductible Health Plan and Healthcare Savings Account.
Waiving Health Insurance Coverage
Use this questionnaire to find out what you need to do to waive medical insurance.
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Keep in mind:
- The only time you can make changes to your benefits outside of Open Enrollment is if you experience a qualifying life event. The Change My Coverage page tells you what events qualify.
- You have to provide proof that you have other medical coverage. That coverage has to meet the IRS definition of Minimum Essential Coverage.
- As you answer the questions below, the system will tell you what to do if you qualify to waive coverage. You may need to send a Waiver of Medical Insurance form and proof of other insurance coverage to SEGIP.
Waiving Medical Insurance Questionnaire