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SF 5142

Coverage requirement of medical services and prescription medications for the treatment of dementia

2025-2026 Regular Session Introduced by Julia Coleman and 2 co-sponsors

Health plans must cover all FDA-approved dementia treatments and related diagnostics without step therapy, effective for plans issued or renewed after Jan 1, 2027.

Referred to Commerce and Consumer Protection
#drugsandmedicine #insurance #insurance-health
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Bill Summary · SF 5142

Summary of SF 5142 (2025-2026) — Coverage for Dementia Treatment and Related Policy Changes

Purpose and intent

SF 5142 seeks to expand health insurance coverage for dementia treatment in Minnesota. The bill requires health plans to cover every type of medical service and prescription medication approved by the U.S. Food and Drug Administration (FDA) that is used to treat or slow the progression of dementia, including coverage for diagnostic testing to determine appropriateness or effectiveness. It also prohibits step therapy for the dementia-related coverage required, aiming to ensure patients can access appropriate treatments without administrative barriers.

Key effective date:
- Section 1 (dementia coverage requirement) becomes effective January 1, 2027 and applies to health plans offered, issued, or renewed on or after that date.

Main provisions

Section 1 — Coverage for Dementia (new law in Minn. Stat. § 62Q.546)

  • Health plan companies must provide coverage for:
    • Every FDA-approved medical service used to treat or slow dementia progression.
    • Every FDA-approved prescription medication used to treat or slow dementia progression.
    • Diagnostic testing necessary to determine the appropriateness or effectiveness of a dementia treatment.
  • Prohibition on step therapy for the dementia-related coverage (i.e., no requirement to first try less expensive or alternative therapies before approving the prescribed dementia treatment).

Section 2 — Amendments to Prior Authorization (Minnesota Statutes § 256B.0625, subd. 13f)

  • Updates to the Formulary Committee’s role:
    • The committee reviews and recommends drugs that require prior authorization (PA). It sets general criteria for PA, especially for brand-name drugs with generic equivalents available, but is not required to review every brand-name drug if a generic exists.
  • PA process and oversight:
    • The commissioner may require PA for certain formulary drugs, with processes including:
    • The commissioner providing information on potential impacts on care quality and program costs, abuse/misuse risk, and relevant Medicaid data (if available).
    • The Formulary Committee reviewing the drug with medical/clinical data and information from the commissioner.
    • A public forum and 15-day public comment period before final PA decisions.
    • A 15-day notice period before implementing PA.
  • Specific exemptions and streamlined pathways:
    • Certain atypical antipsychotics: PA is not required if no generic is available or if the drug is part of the patient’s current/previous treatment and there are conditions tied to longstanding use.
    • Automatic PA: Brand-name antipsychotics prescribed for mental illness receive automatic PA for 60 days when a generic becomes available if the brand was part of the patient’s course at that time.
    • Liquid methadone: PA not required if only one version exists; if multiple versions exist, at least one must be available without PA.
    • Oral liquid forms of drugs: PA may be required, but automatic approval within 24 hours is mandated for enteral-tube patients when prescribed for FDA-approved conditions.
    • If multiple liquid forms exist, the commissioner can select a version suitable for enteral administration.
  • Automatic PA for new FDA-approved drugs:
    • The commissioner may automatically require PA for up to 180 days for drugs approved by the FDA on or after July 1, 2005, with the Formulary Committee providing general PA criteria (not per-drug review).
  • HIV/AIDS treatment:
    • Prior authorization or step therapy must not be required for any drug class approved by the FDA for HIV/AIDS treatment or prevention.
  • Effective date for these PA provisions:
    • January 1, 2027.

Affected parties

  • Health plan companies in Minnesota (insurance issuers offering plans that cover medical services and prescription medications).
  • Minnesota residents enrolled in health plans, particularly those seeking dementia treatment and related diagnostic testing.
  • Providers and pharmacists who prescribe dementia therapies and navigate prior authorization processes.
  • State Formulary Committee and the Minnesota Department of Commerce (overseeing PA and formulary rules).

Procedural and timeline notes

  • The bill was introduced and referred to the Commerce and Consumer Protection committee on April 15, 2026.
  • The dementia coverage mandates take effect for plans issued, offered, or renewed on or after January 1, 2027.
  • PA-related provisions also take effect January 1, 2027, with a framework allowing public input and defined timelines for decisions.

This bill prioritizes access to dementia treatments by guaranteeing coverage and minimizing delays from step therapy and complex prior authorization, while preserving structured oversight of formulary decisions.

Compiled from official sources — confirm details with the bill’s official record.

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