Medicaid Prescription Coverage: What You Need to Know

Does Medicaid Cover Prescriptions? – Overview

The short answer is yes, but coverage varies from state to state.

If you’re an enrollee with a Medicaid card or an eligibility letter confirming that you’re 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 medications purchased from pharmacies that participate in the Medicaid program. 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 you’re getting drugs covered by Medicaid, you’ll 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 don’t have the card yet, you can use your eligibility letter.

The eligibility letter temporarily verifies Medicaid enrollment and benefits until the Medicaid card is received.

How Many Prescriptions Does Medicaid Pay for in A Month?

Medicaid’s monthly prescription coverage policies vary by state—with some states imposing numerical limits and others offering unlimited coverage under certain plans.

Some states are more generous than others, and laws frequently change in response to the introduction of new prescription medications or increases or decreases in aid.

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 you’ll 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.

It’s 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 Medicaid’s 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; Medicaid requires the use of participating pharmacies, and coverage may be denied if non-participating pharmacies are used.

However, after you receive your card, finding a pharmacy approved by Medicaid will be necessary so that your coverage isn’t interrupted.

Does Medicaid Pay for OTC Medication?

Medicaid may cover prescribed OTC medications if they are included in the state Medicaid formulary and deemed medically necessary.

Medicaid covers medications, including prescribed OTC drugs, that are part of the state Medicaid formulary; FDRP participation applies primarily to prescription drugs.

Medicaid covers prescribed OTC medications under the monthly benefit limit, with coverage generally favoring cost-effective options that may include both generic and brand-name drugs based on state policies.

A list of approved OTC medications is available on the applicable state Medicaid website or by contacting the local Medicaid office.

Individuals enrolled in Medicaid Family Health Plus and Managed Care can get pharmacy benefits directly via their Medicaid Managed Care 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.

Medicaid typically covers cost-effective OTC medications, usually generics, but may cover branded products if they are less expensive under state guidelines.

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 can range approximately from $0 to $2 for OTC medications, $0 to $4 for generic drugs, and $4 to $8 for branded drugs.

The drugs on the ‘preferred list’ 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 Medicaid’s 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.

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Does Medicaid Cover Prescriptions