Over 72 million Americans are enrolled in Medicaid, the low-income health insurance program administered by each state. Among other benefits that CDPAP caregivers must understand, the program offers prescription drug coverage for the enrollees. Continue reading to learn more about the types of drugs that are covered, maximum copay amounts, and filling Medicaid prescriptions.

What Is Medicaid?

Medicaid is a joint federal-state program that provides health coverage for low-income individuals and families. The program covers a range of medical services, depending on the beneficiary’s age, income, and family situation. 

State participation in Medicaid is voluntary, but all states currently offer the program. Each state has the right to determine the scope and types of health care services that are covered, as well as reimbursement rates and eligibility standards.

Who is eligible for Medicaid? 

The following groups are eligible for Medicaid:

  • People over the age of 65
  • Children under the age of 18
  • Individuals responsible for a child under the age of 18
  • Pregnant women
  • People who are certified blind by the Commission for the Blind and Visually Handicapped 
  • Individuals with a disability or who have a family member in the same household with a disability, certified disabled by Social Security or the state.

Some states choose to cover other groups, for example, people who are receiving home and community-based services and children in foster care who are not otherwise eligible.

In addition, to benefit from Medicaid, you have to meet the following criteria:

  • You must be a resident of the state in which you are receiving Medicaid
  • You must be a US citizen, national, permanent resident, or legal alien. Undocumented immigrants are covered by Medicaid exclusively for emergency treatments and prenatal care
  • You must be in need of health care and/or insurance assistance
  • You must have a financial situation that is either low income or very low income.

What services are covered by Medicaid?

Federal law requires states to provide certain mandatory benefits to all enrollees, while it allows optional coverage of other services.

Mandatory Medicaid benefits common for all states include:

  • Physician services
  • Inpatient and outpatient hospital services
  • Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
  • Nursing Facility Services
  • Home health services
  • Laboratory and X-ray services
  • Family planning 
  • Nurse midwife services
  • Transportation to medical care
  • Tobacco cessation counseling for pregnant women.

Some of the optional Medicaid benefits include:

  • Prescription drugs
  • Clinic services
  • Physical therapy
  • Occupational therapy
  • Speech, hearing, and language disorder services
  • Optometry services
  • Dental Services
  • Private duty nursing services
  • Personal care
  • Hospice care
  • Case management
  • Intermediate care facility for individuals with intellectual disability
  • Self-Directed Personal Assistance services
  • Inpatient psychiatric services for individuals under the age of 21.

Keep reading to learn more about Medicaid prescription coverage. 

Does Medicaid Cover Prescriptions?

Under federal law, prescription drug coverage is optional for state Medicaid programs. However, all fifty states and the District of Columbia currently provide coverage for outpatient prescription drugs to eligible individuals under the Medicaid Drug Rebate Program (MDRP).

Although Medicaid does pay for prescription drugs, the program may vary from state to state. Not all prescriptions are completely covered and states can choose which prescription drugs they will cover. 

Are brand name drugs covered by Medicaid?

In general, Medicaid programs prefer to pay for generic drugs if they are available, since they work the same way and are as efficient as the more expensive brand name drugs. 

In some cases, Medicaid will pay for brand name drugs, for example, if there is no other alternative or if the prescriber specifies that the brand name drug is medically necessary. 

Drugs Excluded From Medicare Coverage by Law That May Be Covered by Your State’s Medicaid Program

In many states, Medicaid covers some drugs that are excluded from Medicare coverage by law, such as:

  • Drugs for:
    • Anorexia, weight loss, or weight gain
    • Fertility
    • Cosmetic purposes or hair growth
    • Relief of cold symptoms like a cough or stuffy nose
  • Prescription vitamins and minerals except for prenatal vitamins and fluoride preparations
  • Non-prescription (over-the-counter) drugs.

Will I Still Pay a Copay for Prescriptions That Are Covered by Medicaid?

A Medicaid copay is an out-of-pocket cost determined by each state. A state can require copays for different medical services covered by Medicaid, including drug prescriptions. Both prescription and over-the-counter drugs are subject to copay.

Preferred vs non-preferred brand name drugs

Medicaid copays vary based on the classification of the prescribed drug in your state, that is, whether it’s considered a generic, preferred brand-name, or non-preferred brand-name drug. 

Preferred brand-name drugs are safe and effective alternatives to other more expensive brands. That’s why your state may attach a higher copay or require prior authorization for drugs that are not on its preferred brand name drugs list.

Medicaid copay limits

Federal law imposes limits on how much the states can require patients to pay for prescriptions that are covered by health care benefits. 

For preferred drugs, the Medicaid maximum copay limit is $4. 

For non-preferred drugs, your state may require copays of up to $8 if your income is at or below 150% of the federal poverty level (FPL). If your income is above 150% FPL, copayments for non-preferred drugs may be up to 20% of the cost of the drug. 

The FLP annual incomes for 2021 are: 

  • $12,880 for individuals
  • $17,420 for a family of 2
  • $21,960 for a family of 3
  • $26,500 for a family of 4.

The Medicaid copay is limited to 5% of your household income per quarter, also known as your “cost-sharing limit.” After you reach this limit, you won’t have to pay any copays for the rest of the month. 

Exemptions from Medicaid copay

The following groups are exempt from Medicaid copay:

  • Children under the age of 18
  • Pregnant women
  • People who have reached their quarterly limit of Medicaid copay
  • People who are terminally ill, including patients in hospice
  • Medicaid recipients who are living in a nursing home or another long-term care facility
  • Alaska Natives and American Indians who have received treatment from the Indian Health Service, tribal health programs, or under contract health services referral
  • Women in the Breast and Cervical Cancer Treatment Medicaid Program whose income is below the federal poverty level. 

What if I can’t afford a copay?

Since Medicaid covers low-income and very sick patients, health care services can’t be withheld if you’re unable to pay. In other words, you will have access to medical care even if you don’t belong to the exempt group and can’t pay the out-of-pocket expense. However, if you’re not exempt, you might still be billed for the unpaid amount at a later date.

Read on for the details on filling your Medicaid prescriptions.

Where Can I Fill My Medicaid Prescription?

You can fill your Medicaid prescription in any pharmacy that accepts Medicaid as well as in all CVS pharmacies. 

Refillable medications

You will typically have to use at least 75-90% of the medication before refilling, depending on the type of the drug. Your state may also limit the number of refills allowed and the total number of prescriptions or brand name drugs you can access per month without prior authorization. Medicaid doesn’t reimburse for a prescription refill with greater frequency than necessary unless you can document extenuating circumstances.

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