Medical

Care is coordinated through your Primary Care Clinic (PCC). You need preapproval or a referral from your PCC to see most specialists. If you do not get a referral, your insurance doesn’t pay for the care you receive. 

Take a look at real-life common situations where people end up paying their entire medical bill because they didn’t start with their PCC. Call the number on the back of your Blue Cross or HealthPartners ID card if you have any questions.

You do not need a referral to get care from:

• Obstetricians/gynecologists
• Chiropractors for acute care
• Mental health providers
• Substance use disorder providers
• Eye doctors for routine eye exams

The provider must be in your Blue Cross or HealthPartners network. Call the number on the back of your medical insurance ID card to make sure the provider you want to see is in network. If you see a provider who is not in your network, you pay the entire bill yourself. The Minnesota Advantage Health Plan does not have coverage for out-of-network care.

If you have diabetes this benefit helps you take care of yourself and lowers the chances you’ll have complications. 
Learn more about the Advantage Value for Diabetes pilot program. The program offers lower cost or free diabetes-related medical care such as:

• Physician office visits
• Diabetes educator and dietitian office visits
• Tests
• Consultation with a pharmacist 

You also save on prescription drugs that treat diabetes, hypertension, cholesterol, and depression, as well as diabetes testing supplies.
Also, people with type 1 or type 2 diabetes who are covered under the Minnesota Advantage Health Plan are eligible for a personal health coach and certified diabetes educator through Omada. 
Learn more about care for people with diabetes.

Are you or your family members eligible for a personal health coach? 

Check out the Omada benefit if you:

• Have medical coverage through the state's Minnesota Advantage Health Plan.
• Are at least 18 years old.
• Are interested in weight loss.
• Have a condition such as prediabetes, high blood pressure, or abnormally high or low amounts of lipids or lipoproteins in your blood such as bad (LDL) or good (HDL) cholesterol. 
• If you smoke or use other tobacco today or have in the past.

Fertility insurance benefits help potential parents who are struggling to conceive or carry a pregnancy to term. The coverage includes free access to experts or nurse guides who can answer questions, help you compare your options, and provide ongoing support throughout the fertility treatments. You do not need an infertility diagnosis to use this benefit. Learn more.

Mental health care is now more affordable for state employees and their family members covered by the Minnesota Advantage Health Plan. Highlights include: 

• Some mental health office visits are free if your primary care clinic is a cost level 1 or 2. 
• You will save $20 at each allowed mental health office visit if your primary care clinic is cost level 3 or 4. You have to pay your deductible before insurance starts to pay for your care. 
• You may see any mental health provider in your network. You do not need a referral from your primary care clinic.

Learn more, including options for care you can get online.

Is the care you need more than 100 miles from home? The travel benefit may help you pay for lodging and more when you must travel for care. Learn more.

The travel benefit is not available for routine office visits or when online care is an option.

First, contact Blue Cross or HealthPartners to find out which convenience clinics are in your network. (Just because a clinic calls itself convenient, doesn’t mean it meets the definition of a Convenience Clinic in your network.)

Yes. It can be confusing, but a simple phone call will make sure you don’t end up with an unexpected bill.

• Most employees and family members with the Minnesota Advantage Health Plan do not pay for care they get at official in-network convenience clinics. (There's no copay, and insurance pays even if you haven’t met your deductible.)
• There are about 300 employees and their family members who chose to sign up for the high deductible plan. If you’re one of them, you must pay your full deductible before the care you get at a convenience clinic is free to you. 

Convenience clinics are less expensive for you and the state. Care such as simple illnesses, tests, and shots is provided by a nurse practitioner or physician assistant. You usually don't need an appointment.

You don't pay for care you get online through Doctors on Demand or virtuwell. If HealthPartners is your plan administrator Teladoc is also an online option for you. 

But online care for the same medical concern through other clinics, including your primary care clinic, could require you to pay.

It can be confusing. Call the number on the back of your Blue Cross or HealthPartners medical insurance ID card to learn about which online care is free, and when you’d have to pay.

• You do not need a referral to get care online through Doctors on Demand, virtuwell, or Teladoc.
• You do not have a copay. Insurance pays for the entire visit.
• You do not have to meet your deductible before insurance starts to pay, unless you signed up for the Advantage High Deductible Plan.

Find out how office visits for mental health or substance use disorder care are covered. Some care may be free in person as well as online.

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:

• Select “Commercial Prior Authorization and Notification List.”

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:

• Choose Product: Minnesota

• Choose Prior authorization required: Yes

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.

• Select the specific medicine to find the prior authorization details.

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.  

• Obstetricians/gynecologists

• Chiropractors for acute care

• Mental health providers

• Substance use disorder providers

• 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:

• How much the plan will pay for the care you need.

• How much you need to pay for your care.

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:

• 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.

• Nonformulary Generic: Log into your CVS account. Search by drug name and zip code to get a price.

• Preferred brand and Formulary brand: You pay $30 for a 30-day supply.

• Nonpreferred brand: You pay $55 for a 30-day supply.

• Nonformulary brand: Log into your CVS account. Search by drug name and zip code to get a price.

You also need to know:

• Copays are different for some medications that treat people who have diabetes. Go to the Advantage Value for Diabetes drug list for more details.

• 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.

• The yearly out-of-pocket maximum for prescriptions is $1,050 for single coverage, $2,100 for family.

• 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.

• Get most prescriptions filled at any pharmacy in the CVS Caremark network. The network includes pharmacies not owned by CVS Caremark.

• You must get specialty drugs through CVS Specialty. Specialty medications usually treat more complex conditions.

• 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.

Minnesota Advantage Health Plan is the health insurance coverage for state employees, and retirees under age 65 and/or not eligible for Medicare. Employees pick either Blue Cross and Blue Shield of Minnesota or HealthPartners to administer their coverage. In addition, employees 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.

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.

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