Medicaid covers most prescription drugs, but not all, and what your state covers depends on which Medicaid program you are in

Medicaid does cover prescription medications for most people enrolled in the program. However, the specific drugs covered vary by state and by which Medicaid category you fall into — whether you receive Medicaid through your state's main program, through a managed care plan, or through a special category like pregnancy or disability. Your state Medicaid agency maintains a list called a formulary that shows which drugs are covered and which are not.

The drugs Medicaid must cover include all FDA-approved medications for certain conditions, but states can exclude some drugs or require you to try a cheaper option first. If your doctor prescribes a drug that is not on your state's formulary, you can ask your doctor to request an exception, or you can ask your pharmacy to check whether a similar drug on the formulary would work instead.

Key Takeaways

  • Every state's Medicaid program publishes a formulary — a list of covered drugs — and you can view your state's formulary online or call your Medicaid caseworker to ask whether a specific drug is covered.
  • Medicaid may require you to pay a small copay at the pharmacy, usually between $0.50 and $3 per prescription, though some states waive copays for certain groups like pregnant people or children.
  • If your doctor prescribes a drug not on the formulary, you can request a prior authorization or exception, which usually takes a few business days to process.
  • Managed care Medicaid plans may have different formularies than your state's main Medicaid program, so you need to check your specific plan's list.

How to learn about a specific drug is covered

The fastest way is to call your Medicaid caseworker or your managed care plan and give them the drug name and strength. They can tell you in minutes whether it is on the formulary and what your copay will be. If you do not know your caseworker's number, call your state Medicaid agency — the number is on your Medicaid card or on your state's Medicaid website.

You can also check your state's formulary yourself online. Most states post their formulary as a searchable PDF or database on their Medicaid website. Search for "[your state] Medicaid formulary" to find the link. If you are in a managed care plan, your plan's formulary may differ from the state's main list, so check your plan's website or call the member services number on your insurance card.

If you are at the pharmacy and the drug is not covered, the pharmacist can often tell you which similar drugs are covered. This is called a therapeutic alternative. Your doctor can switch you to one of those drugs, or your doctor can submit a request for an exception.

What happens if your drug is not on the formulary

If your doctor prescribes a drug that Medicaid does not cover in your state, your doctor can request a prior authorization or exception. This is a formal request to Medicaid asking them to cover the drug anyway, usually because you have already tried other drugs that did not work or because you have a medical reason the drug is necessary.

Your doctor's office submits this request to your state Medicaid program or to your managed care plan. The request usually takes three to five business days to process, though urgent requests can be decided faster. Medicaid will either approve the request, deny it, or ask your doctor for more information. If approved, the drug becomes covered for you, and you pay your normal copay.

If Medicaid denies the request, your doctor can appeal the decision or suggest a different drug. You can also ask your doctor whether paying out of pocket for the drug makes sense, or whether a covered alternative would work for your condition.

Copays and cost-sharing for prescriptions

Most Medicaid programs charge a small copay when you pick up a prescription. The copay is usually between $0.50 and $3 per prescription, depending on your state and the type of drug. Some states charge more for brand-name drugs than for generic versions of the same drug.

However, many states waive copays for certain groups: pregnant people, children under a certain age, people in nursing homes, and people receiving Medicaid for a disability. If you think you should not have to pay a copay, ask your Medicaid caseworker or call the number on your Medicaid card.

If you cannot afford the copay, tell the pharmacist or your Medicaid caseworker. Some states have programs that help people pay copays, and your caseworker can tell you whether you may have access to.

Generic drugs versus brand-name drugs

Medicaid covers both generic and brand-name drugs, but most Medicaid programs encourage you to use generic versions when they are available. A generic drug has the same active ingredient and strength as the brand-name drug but costs less. Your copay for a generic drug is usually lower than for the brand-name version.

If your doctor wants you to take the brand-name drug instead of the generic, they can request a brand medically necessary exception. This tells Medicaid that the generic version will not work for your medical condition. Your doctor's office submits this request, and Medicaid decides whether to approve it. If approved, you can take the brand-name drug at the generic copay rate, or at a slightly higher copay.

Special drug categories and restrictions

Medicaid may place restrictions on certain drugs to make sure they are used safely and appropriately. For example, some drugs require a prior authorization before the pharmacy can fill the prescription — meaning your doctor has to get approval from Medicaid first. Other drugs may be limited to a certain number of pills per month, or may require you to try a cheaper drug first before Medicaid will cover a more expensive one.

These restrictions are most common for drugs that are expensive, that can be abused, or that have serious side effects. Your pharmacist can tell you whether your prescription has a restriction, and your doctor can request an exception if the restriction does not make sense for your medical situation.

What to do if you cannot afford your medication

If your copay is too high or if your drug is not covered, you have several options. First, ask your doctor whether a covered generic drug would work instead. Second, ask your Medicaid caseworker whether you may have access to for a copay waiver or assistance program. Third, ask your pharmacist whether the drug manufacturer offers a discount program or patient assistance program — many do, even for people on Medicaid.

You can also contact your state Medicaid agency directly and explain your situation. Some states have emergency funds or hardship programs for people who cannot pay for necessary medications. Your caseworker can tell you what is available in your state.

Frequently Asked Questions

Do I have to use a specific pharmacy for Medicaid prescriptions?

No. You can use any pharmacy that accepts Medicaid. Most large chain pharmacies and independent pharmacies accept Medicaid. Call ahead if you are unsure, or ask the pharmacy whether they take your specific Medicaid plan.

What if my doctor prescribes a drug and the pharmacy says it is not covered?

Call your Medicaid caseworker or your managed care plan to confirm whether the drug is on the formulary. If it is not, ask your doctor to request a prior authorization or to suggest a covered alternative. Do not leave the pharmacy without a plan — the pharmacist can help you figure out your next step.

Can I get a 90-day supply of my prescription instead of a 30-day supply?

Many Medicaid programs allow 90-day supplies for maintenance drugs — medications you take regularly for a chronic condition. Ask your pharmacist or your doctor whether your prescription qualifies. A 90-day supply may have a higher copay or the same copay as a 30-day supply, depending on your state.

Does Medicaid cover over-the-counter drugs?

Most Medicaid programs do not cover over-the-counter drugs like pain relievers or cold medicine. However, some states cover certain over-the-counter drugs if your doctor prescribes them. Ask your doctor or your Medicaid caseworker whether a specific over-the-counter drug is covered.

What if I move to a different state?

Your Medicaid coverage transfers to your new state, but the formulary and copays may be different. Contact your new state's Medicaid agency within 30 days to update your address. Ask them for a copy of the new state's formulary and find out whether your current medications are covered. Your doctor may need to request exceptions for drugs that are not on the new formulary.