Does Medicaid Cover Prescriptions? ā Overview
The short answer is yes, but coverage varies from state to state.
If youāre an enrollee with a Medicaid card or an eligibility letter confirming that youāre a Medicaid recipient, you can buy prescription drugs that Medicaid covers.
However, before you go out and start getting prescription medication with your Medicaid coverage, you need to know the specific drugs that Medicaid can pay for and where you can purchase these drugs.
Medicaid will pay for prescription meds bought from specific drug stores. The only way to determine whether your favorite pharmacy is approved to sell drugs by Medicaid is to contact your local Medicaid office or speak to the pharmacy directly.
So, as long as youāre getting drugs covered by Medicaid, youāll be visiting a drug store participating in the Medicaid program.
You can use your Medicaid card when you get there, but if you enrolled recently and donāt have the card yet, you can use your eligibility letter.
The eligibility letter is a form of ID that gives you access to Medicaid benefits for prescription medications and other services.
How Many Prescriptions Does Medicaid Pay for in A Month?
The rules and regulations vary from state to state about how many prescriptions Medicaid can pay for each month.
Some states impose monthly prescription limits (while others offer unlimited coverage), and these policies have often changed recently. Many states have raised or eliminated prescription caps and adjusted coverage in response to new medications and funding changes.
Contact your local Medicaid office or representative to fully understand the details surrounding prescription meds and the number of times that Medicaid will cover them each month.
Depending on which prescription meds you need, the number of tablets or capsules youāll get will vary depending on the meds.
State Medicaid outlets list their preferred drugs along with their limits to make these limits clear and crisp for both patients and pharmacies.
So, check with your coverage provider to see which drugs are covered under your plan.
Do All Pharmacies Accept Medicaid Payment?
No, only pharmacies participating in the Medicaid program accept this form of payment.
However, just like hospitals and physicians, you must check and confirm if your favorite pharmacy is in your State Medicaid preferred pharmacy list.
Itās essential to ask for clarification because getting prescription meds in a pharmacy that Medicaid does not approve can result in you having substantial out-of-pocket costs and less efficient use of your Medicaid health plan.
The first place to check if your favorite or local pharmacy will accept Medicaid coverage is your State Medicaidās list of providers.
Most state Medicaid programs have a list on their websites that can be accessed anytime.
You must use a Medicaid-approved pharmacy to receive coverage for your prescription medications from the time you are enrolled in Medicaid; there is no grace period for using non-approved pharmacies.
However, after you receive your card, finding a pharmacy approved by Medicaid will be necessary so that your coverage isnāt interrupted.
Does Medicaid Pay for OTC Medication?
Medicaid will pay for OTC (over-the-counter) meds if you have gotten a prescription from a doctor either verbally, in writing, or via electronic text.
Medicaid will only cover drugs (including eligible OTC medications) from manufacturers that participate in the Medicaid Drug Rebate Program, and as of 2024 a federal law removed the prior cap on total rebate amounts manufacturers must pay.
Although Medicaid covers OTC meds in the monthly drug benefit limit, all these drugs are considered generic even if the name of the company that manufactures the drug is indicated.
A list of approved OTC meds is available on Medicaid.ms.gov.
Individuals enrolled in a Medicaid managed care plan receive pharmacy benefits directly through that plan.
Coverage for OTC medications not on the approved list may be available under EPSDT for recipients under 21 with a prescription and prior authorization, depending on state-specific Medicaid guidelines.
Examples of OTC meds that Medicaid pays for include:
1. Aspirin
2. Acetaminophen
3. Permethrin Lotion.
4. Pseudoephedrine
5. Zinc Oxide Treatment.
As a general rule, Medicaid will only pay for generic OTC meds. However, in some instances, branded drugs could be cheaper.
Medicaid coverage for OTC medications, including those for discomfort or pain, is determined by state-specific guidelines and may require a prescription from a healthcare provider.
Medicaid coverage for cough and cold medications and vitamins, including prenatal vitamins, varies by state and may require a prescription or prior authorization based on state-specific guidelines.
What Are the Out-of-Pocket Costs for Prescriptions with Medicaid Coverage?
The precise method used to calculate the out-of-pocket costs for prescription meds covered by Medicaid is somewhat complex.
The method is based on various elements and factors, so it can be difficult to know or understand the prices of different Medicaid-covered prescriptions.
Medicaid co-payment amounts vary by state and typically range from $0 to $2 for OTC medications, $0 to $4 for generic drugs, and $4 to $8 for brand-name drugs. The drugs on the āpreferred listā of most State Medicaid programs are the most affordable. The list also includes the most practical and effective medications available.
When pricing prescription meds covered by Medicaid, a balance must be struck to enable pharmaceutical enterprises and pharmacies to cover their expenses.
It also enables them to keep the price low enough that the government can afford to almost fully cover these prescription medications on behalf of the recipients.
As a result, the cost of prescription meds varies a lot.
Final Thought
What Medicaid covers about prescription drugs varies from state to state. As a result, always talk to your physician about the meds you need and Medicaidās cost structure for these meds.
In addition, note that the law forbids private billing of Medicaid beneficiaries, so if this happens, contact your local Medicaid office as soon as possible.
See Also
What Prescription is Legally Blind
Does Medicaid Cover Assisted Living
