Medicaid is a joint federal-state program that pays for health care services for people with low incomes or disabilities. Prescription drugs are included in this benefit, although certain limitations may apply depending on what state you live in. Read this article to find out more about Medicaid prescription coverage.
What is Medicaid?
Medicaid is a state and federally funded program that covers medical assistance and long-term care for individuals and families with low incomes and relatively few assets. The program pays for doctors’ bills and other health costs for all individuals who qualify. It covers 1 in 5 Americans and is the main source of long-term care coverage in the country.
Mandatory and optional Medicaid benefits
Medicaid coverage differs from state to state, however, all states are required to provide the mandatory Medicaid benefits, including:
- 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.
In addition, each state can choose to offer optional benefits, such as:
- Prescription drugs
- Clinic services
- Physical therapy
- Optometry services
- Dental Services
- Private duty nursing services
- Personal care
- Hospice care
- Intermediate care facility for individuals with intellectual disability
- Self-Directed Personal Assistance services
- Inpatient psychiatric services for individuals under the age of 21.
Who is eligible for Medicaid?
The following groups qualify for Medicaid:
- Children under the age of 18
- People responsible for a child under the age of 18
- People over the age of 65
- Pregnant women
- Individuals who are certified blind by the Commission for the Blind and Visually Handicapped
- Individuals with a disability or those who have a household member with a disability, certified disabled by Social Security or the state.
- People who are receiving home and community-based services (in some states)
- Children in foster care who are not otherwise eligible (in some states).
To be eligible for the program, you must reside in the state in which you are receiving Medicaid and be either a US citizen, national, permanent resident, or legal alien. In addition, you have to be in need of health care and your financial situation must be defined as low income or very low income.
Prescription coverage is a key component of Medicaid. Read on to find out what drugs are covered and what are copay requirements.
Does Medicaid Cover Prescriptions?
Although Medicaid programs are not required to cover prescriptions under federal law, all states offer coverage for outpatient prescription drugs to Medicaid beneficiaries. Each state can choose which prescription drugs they will cover.
Drugs Excluded From Medicare Coverage by Law That May Be Covered by Your State’s Medicaid Program
Some Medicaid programs cover drugs that are excluded from Medicare coverage by law, for example:
- Drugs for:
- Anorexia, weight loss, or weight gain
- Cosmetic purposes
- Hair growth
- Relief of cold symptoms such as a cough or stuffy nose
- Over-the-counter drugs
- Prescription vitamins and minerals, with the exception of prenatal vitamins and fluoride preparations.
Will I Still Pay a Copay for Prescriptions That Are Covered by Medicaid?
A copay is a small fixed amount that you have to pay for Medicaid-covered health care services after you've paid your deductible. States can impose copayments on any Medicaid benefits, including prescription drugs.
The copay is usually about $3 for a prescription. However, the total monthly amount you will have to pay is limited to 5% of your household income per quarter. After you reach this limit, also known as the “cost-sharing limit,” you won’t have any other copays for the rest of the month.
States have the option to determine alternative out-of-pocket costs for beneficiaries whose income is above 100% of the federal poverty level. You may be denied services for nonpayment of alternative copays.
Exemptions from Medicaid copay for prescription drugs
You are not required to pay copays for prescription drugs if you belong to one of the categories below:
- Children under the age of 18
- Pregnant women
- People who have reached their quarterly limit of Medicaid copay
- Individuals who are terminally ill, including patients in hospice
- Medicaid beneficiaries 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 with income is below the federal poverty level.
Besides, certain types of drugs typically don’t require copays, for example:
- Drugs used to treat substance use disorder as part of medication-assisted therapies
- Some preventive drugs, such as low-dose aspirin for heart conditions, HIV prevention drugs
- Family planning drugs or supplies, including FDA-approved contraceptive drugs or devices
- Drugs to help quit smoking
- Emergency services.
If you can’t afford copay and you don’t belong to the exempt group, you won’t be denied access to medical services, although you may still be held liable for unpaid copays.
Where Can I Fill My Medicaid Prescription?
You can fill your prescription in all Medicaid-approved pharmacies and CVS pharmacies. The pharmacist must fill your drug prescription even if you can’t afford the copay.
It’s important to keep in mind that states can choose to limit the number of refills and prescriptions or brand name drugs you can access per month without prior authorization. Medicaid doesn’t reimburse prescription refills that are done more frequently than necessary.
According to prescription refill guidelines, you have to use at least 75-90% of the prescribed drug before refilling, depending on the type of the drug.
Does Medicaid Cover Brand Name Drugs?
In most cases, Medicaid programs prefer to pay for generic drugs. These drugs have the same active ingredients and are therapeutically equivalent to the more expensive brand name drugs.
Medicaid will cover brand name drugs only if generic alternatives are unavailable or if a specific brand name drug is necessary for your treatment. This must be certified by your health care provider.