What Medicaid Covers

Although it is an "optional" coverage under federal law, all 50 states plus the District of Columbia include prescription drug coverage in their Medicaid plans.

States are permitted to impose limits and restrictions on the prescription benefit within limited guidelines. Some of the restrictions used by various states include:

• Prescription Limits. Some states limit the number of prescriptions a recipient can obtain with either a monthly or annual cap (see the list above). A few, but not all, states with such limits allow exceptions, such as for life-threatening illnesses or for certain classes of drugs, such as HIV/AIDS drug cocktails. Generally, states cannot offer prescription drugs to people who are eligible for both Medicare and Medicaid. People with such dual eligiblity must get their drugs from Medicare Part D plans. States can (and some do) cover certain narrow classes of drugs excluded by Medicare Part D. If they are willing to do so without federal matching, all states can offer any drugs they desire to people who are also eligible for Medicare.
• Copayments.
• Some states require a copayment of from $.50 to $5.00 per prescription. These copayments are often waived for certain groups of Medicaid recipients.
• Copayments are prohibited for recipients under 18 years old, pregnant women, and residents of certain institutions.
• Note: federal regulations prohibit denying access to medications or other medical servivces because of a recipient's inability to pay the copayment.
• Drug Formularies.
• A formulary is a list of medications that will be covered under a health plan. Many, but not all, states have Medicaid formularies.
• Each state must have an appeal/exception mechanism for obtaining medically necessary medications that are not on the formulary.

The federal government also permits states to refuse or limit coverage for certain types of drugs. These include:

• Anorexia, weight loss, or weight gain drugs.
• Fertility drugs.
• Medications for cosmetic or hair growth purposes.
• Vitamins and minerals.
• Drugs for smoking cessation.
• Cough and cold symptom medications.
• Nonprescription drugs.

For details about the Medicaid prescription plan in your state, you can check: www.kff.org/medicaid/benefits/service.jsp?gr=off&nt=on&so=0&tg=0&yr=3&cat=5&sv=32

NOTE: Pharmacists or their assistants are required to offer prescription medicine counseling to Medicaid patients and to review their medicine usage. Mail-order pharmacies must provide toll-free telephone service. The offer to counsel must include all important aspects of the medicine, such as its description, dosage form, length of treatment, special directions, common severe side effects, interactions and their avoidance or remedy, storage, the way to handle a missed dose, and techniques for self-monitoring treatment, such as blood testing by diabetics.

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