Paying for Epilepsy Care in Minnesota¶

Epilepsy costs money in two places: the appointments and the pills. This chapter covers the Minnesota programs that help with each, what a prior authorization is, how to fight a denial, and what these medicines actually cost.

Read this first

This is general information, not medical, legal, or financial advice. Program rules and income limits change every year, and only the agency that runs a program can tell you whether you qualify. Nothing here tells anyone to start, stop, or change a medicine. This page was written by students from public sources and has not yet been reviewed by a clinician or the Epilepsy Foundation of Minnesota. We are seeking that review. In an emergency, call 911.

Apply even if you think you earn too much¶

That is the single most useful sentence on this page. Minnesota has more than one door, and the door for a child with a disability ignores the parents' income entirely. Families skip the application because of a number they read somewhere, and then pay for years of care they did not have to pay for.

Medical Assistance¶

Medical Assistance is Minnesota's Medicaid program. State law sets the income limits as a percentage of the federal poverty guidelines, and they differ a lot by group (Minn. Stat. 256B.056, subd. 4):

Who	Income limit
Children under 19	up to 275% of federal poverty guidelines
Children ages 19 and 20	up to 133%
Parents and caretaker relatives	up to 133%
Adults without children	up to 133%
People who are 65 or older, blind, or have a disability	up to 100%

Asset limits apply to some groups and not others. The statute sets no asset limit for children under 21 or for adults without children, and sets dollar limits for other groups (subd. 3). The eligibility categories themselves, including pregnancy, foster care, and disability, are listed in Minn. Stat. 256B.055.

Apply through your county or tribal human services office, or through MNsure. The Department of Human Services program pages are at mn.gov/dhs.

MinnesotaCare¶

MinnesotaCare sits just above Medical Assistance. It covers people with household income above 133% and at or below 200% of the federal poverty guidelines, for families with children and for adults without children alike (Minn. Stat. 256L.04). If you qualify for Medical Assistance, you are not eligible for MinnesotaCare, so one application sorts you into the right one.

Most enrollees pay a monthly premium on a sliding scale set by the commissioner. Two groups pay nothing: people 20 years old and younger, and people with household income below 35% of the federal poverty guidelines. American Indians enrolled in MinnesotaCare have their premiums waived (Minn. Stat. 256L.15).

TEFRA, for a child whose family earns too much¶

Ask about TEFRA by name. It is the option most families have never heard of, and it exists precisely for the household that was turned down on income.

TEFRA is Medical Assistance for a child under 19 who has a disability and who needs a level of care usually given in a hospital, a nursing facility, or an intermediate care facility for people with developmental disabilities, where care at home costs Medical Assistance no more than care in the institution would (Minn. Stat. 256B.055, subd. 12).

The part that matters most is the money test. The Department of Human Services eligibility policy manual states it in one line:

Only the income of the child is counted when determining eligibility for MA. Parents' income is not counted. (DHS Eligibility Policy Manual 2.3.6)

Parental fees used to follow. They no longer do. In 2023 Minnesota eliminated the parental fees charged to families whose children get Medical Assistance through TEFRA or through home and community-based services, effective that July (DHS news release).

A TEFRA determination involves a disability certification and a level-of-care assessment, so it takes longer than an ordinary application. Start it before you need it.

SSI and SSDI in plain terms¶

These are two different Social Security programs, and people mix them up constantly.

SSI, Supplemental Security Income, is based on need. It pays people who are 65 or older, blind, or have a disability, including children, and who have limited income and resources. It is paid out of general tax revenue, not out of anyone's work record. A child can be eligible from birth and can stay eligible until 18. If the child is under 18, unmarried, and living at home, Social Security counts part of the parents' income and resources as if they belonged to the child (SSA, who can get SSI; SSI for children).

SSDI, Social Security Disability Insurance, is based on work. It pays people who are insured through the Social Security payroll contributions they or, in some cases, a parent have made. You build eligibility through work credits, earned on yearly wages or self-employment income, up to four credits a year (SSA, how someone becomes eligible; Red Book overview).

Both use the same medical definition of disability. Epilepsy on its own is not an automatic qualifier; what matters is what the seizures and the treatment do to daily functioning. Keep a seizure diary with dates, and keep the clinic notes, because that record is what the decision rests on. SSA's guide for families is Benefits for Children with Disabilities.

What a prior authorization is¶

Ask the clinic to file it the same day the pharmacy tells you about it. Nothing moves until the form is in.

A prior authorization is the health plan saying it will not pay for a drug or a service until it reviews the case first. Minnesota law puts clocks on that review. A standard request gets a decision "within five business days after receiving the request." An expedited request, for a situation where waiting would hurt, gets one "no later than 48 hours," and the deadline must include at least one business day (Minn. Stat. 62M.05, subd. 3a and 3b).

Minnesota also bans prior authorization outright for some things, including emergency services (Minn. Stat. 62M.07, subd. 2).

On Medical Assistance and MinnesotaCare, drug authorizations go to Prime Therapeutics, the state's prescription drug authorization agent, and the request comes from your pharmacy or prescriber rather than from you (DHS drug authorizations).

How to appeal a denial¶

Appeal. Denials get overturned often enough that not appealing is the expensive choice.

If you have commercial insurance, there are two stages.

The first is the plan's own internal appeal. You and your treating clinician both have the right to file it. An expedited appeal gets an answer by telephone "no later than 72 hours after receiving the expedited appeal." A standard appeal gets one within 15 days, with up to four more days if something outside the plan's control gets in the way. If the denial stands, the plan must tell you in writing how to go to external review (Minn. Stat. 62M.06).

The second is external review by an independent organization. Anyone acting on the enrollee's behalf can request it, the request has to come within six months of the adverse determination, and the health plan pays for the review, not you. The decision binds the health plan and does not bind you (Minn. Stat. 62Q.73).

Which agency handles it depends on what kind of plan you have. HMO enrollees file with the Minnesota Department of Health, at no cost, with a standard review taking up to 45 days after the case reaches the reviewer and an expedited 72-hour option when a wait could harm you (MDH external appeals). If your coverage is from an insurance company rather than an HMO, the request goes to the Minnesota Department of Commerce (external review appeal).

If you are on Medical Assistance or MinnesotaCare, the route is a state appeal instead. You can appeal when an application is denied, when nothing happens in a reasonable time, or when coverage is cut, reduced, or ended. Ask for the hearing within 30 days of the written notice, or within 90 days if you can show good cause. Assistance ordered in the appeal keeps being paid while the case moves up (Minn. Stat. 256.045, subd. 3 and 10).

The emergency supply, and the words to say¶

Say "emergency supply" at the pharmacy counter. A pharmacist who is not asked may not offer it.

Minnesota has two separate rules, and it helps to know which one you are asking about.

The first is for when nobody can reach your prescriber and the refills have run out. A pharmacist may dispense without a current prescription if you have been filling the drug consistently, the pharmacy has the old prescription on file, the pharmacist has tried and failed to reach a prescriber, the drug is needed to sustain life or continue treatment of a chronic condition, and going without would harm you. The amount is capped at a 30-day supply or the original quantity, whichever is less. For a controlled substance "specifically prescribed to treat a seizure disorder," the cap is a 72-hour supply. The pharmacist has to tell your prescriber within 72 hours, and this can only be done once per drug per 12 months (Minn. Stat. 151.211, subd. 3).

The second is for when a prior authorization is holding up a drug you are already prescribed. Under Minnesota Health Care Programs, a pharmacist may dispense up to a 72-hour supply of a covered medication in an emergency and seek retroactive authorization afterward (DHS drug authorizations). Do not skip doses while the paperwork moves. Our Pharmacy Problem Solver walks through the rest of the counter conversation.

Manufacturer help and NeedyMeds¶

Check for a patient assistance program before you pay a large bill, not after.

Most drug makers run patient assistance programs for people who cannot afford their product. They are all different, and their income rules, paperwork, and exclusions vary. Many exclude people already enrolled in Medicaid or Medicare.

NeedyMeds is a free directory of those programs, plus coupons and diagnosis-based assistance funds. Its helpline is 800-503-6897. If you know the drug, its manufacturer's website usually has the program too. More options are collected on our Resources & Support page.

What these medicines actually cost¶

Two numbers make sense of most pharmacy bills in Minnesota.

The first is the gap between a generic and the brand. Below is the cost to a pharmacy of a 30-day supply at a common adult dose, from the federal NADAC survey as of September 2026. This is what the pharmacy pays, not what you pay, but the ratio carries through to what a plan charges.

Medicine	Generic, 30 days	Brand, 30 days
levetiracetam / Keppra	$4.43	$594.93
lamotrigine / Lamictal	$4.24	$688.16
brivaracetam / Briviact	$11.23	$1,444.77
lacosamide / Vimpat	$12.76	$1,178.68
clobazam / Onfi	$14.84	$1,794.87
cenobamate / Xcopri	no generic exists	$1,196.05

The second is that some medicines have no cheaper version at all. Six antiseizure medicines have no generic anywhere in the United States: Epidiolex, Fintepla, Xcopri, Nayzilam, Ztalmy, and Diacomit. In Minnesota Medicaid in 2025 they were 1.5% of antiseizure prescriptions and 32% of the spending on them. A family whose child needs one of those has nothing to switch to.

Who you are insured by changes the bill more than most people expect. In 2022, Minnesota members paid an average of $18.48 out of pocket per antiseizure prescription on a commercial plan, against $9.30 on Medicare and $1.31 on Minnesota Health Care Programs.

These three figures come from EDAN's own analysis of the CMS NADAC file, the FDA Orange Book, CMS State Drug Utilization Data, and the Minnesota All Payer Claims Database public use files published by MDH. The method and the row-level results are in our Medication Access work.

The $25 cap bill, and where it stands¶

Two bills in the 2026 session would have capped what a commercially insured Minnesotan pays for epilepsy medicine at $25 for a one-month supply.

Minnesota already does this for three other conditions. Minn. Stat. 62Q.481 requires a health plan to limit enrollee cost sharing for drugs treating a chronic disease to "no more than $25 per one-month supply for each prescription drug" and $50 a month for related supplies, and says the coverage is not subject to a deductible. The statute defines chronic disease as diabetes, asthma, and allergies needing epinephrine auto-injectors. Epilepsy is not in that list.

HF 3652, authored by Rep. Greene, and SF 3786, authored by Sen. Abeler with Sen. Boldon, would have added it. Both were introduced on February 23, 2026. HF 3652 went to House Commerce Finance and Policy and picked up eight more authors. SF 3786 went to Senate Commerce and Consumer Protection. Neither got a floor vote, so the idea has to be introduced again in 2027 to go anywhere.

The Department of Commerce priced the change. Using Minnesota claims from 2021 through 2024, it projected epilepsy cost sharing of $44.71 per member per month in 2027, of which $17.35 sits above the $25 line, and put the cost of the mandate at four cents per member per month (Evaluation of Cost-Sharing Limitations for Epilepsy Medications and Supplies, February 11, 2026).

What we could not confirm¶

The dollar figures behind those percentages. Federal poverty guidelines change each year, and the DHS pages that publish the current Minnesota tables refused our automated requests. Get them from MNsure or your county office.
Which Medical Assistance asset limit applies to which group in 2026. The statute lists more than one set of figures and recent sessions have changed them.
Whether an SSI approval opens Medical Assistance automatically in Minnesota. We found no state page saying so plainly either way.
Which manufacturer assistance programs cover which seizure medicines, and on what income rules. There are too many to verify, and they change.
Whether commercial plans in Minnesota must offer the same 72-hour emergency supply that Minnesota Health Care Programs does. We found the rule for the state programs and the pharmacist refill law, and nothing that binds commercial plans.
Out-of-pocket figures more recent than 2022. That is the last year MDH has published in the All Payer Claims Database public use files.

Sources: Minn. Stat. 256B.055, 256B.056, 256L.04, 256L.15, 256.045, 151.211, 62M.05, 62M.06, 62M.07, 62Q.73 and 62Q.481; HF 3652 and SF 3786; Minnesota DHS Eligibility Policy Manual 2.3.6, drug authorizations and news release on parental fees; Minnesota Department of Health HMO external appeals; Minnesota Department of Commerce external review appeal and epilepsy cost-sharing evaluation (2026); Social Security Administration SSI eligibility, SSI for children, disability eligibility, Red Book and Benefits for Children with Disabilities; NeedyMeds; MNsure. Cost figures are EDAN's own, from data/nadac_asm_30day_cost.csv, data/mn_brandonly_asm_summary.md and data/mn_apcd_rx_asm_summary.md. Terms are defined in the glossary. See also Medicines for Epilepsy and Resources & Support.