When you’re on Medicaid, getting your prescriptions shouldn’t mean choosing between medicine and groceries. But understanding what’s covered-and what’s not-can feel like navigating a maze. In 2026, Medicaid still covers prescription drugs for nearly 85 million low-income Americans, but the rules vary wildly from state to state. What’s covered in North Carolina isn’t always covered in Florida. And even within the same state, the drug you need might require jumping through hoops before you can get it.
Medicaid Covers Prescriptions-But Not Always the Way You Expect
Federal law doesn’t require states to cover outpatient prescription drugs under Medicaid. Yet every single state does. Why? Because without drug coverage, people skip doses, end up in the ER, and cost the system more in the long run. The real story isn’t whether drugs are covered-it’s how they’re covered. Most states use a Preferred Drug List (PDL), which sorts medications into tiers. Tier 1 usually means generic drugs with the lowest copay-often $1 to $5. Tier 2 is brand-name drugs that cost more, maybe $15 to $40. Tier 3? That’s for specialty drugs, like those for rheumatoid arthritis or hepatitis C. Those can cost $100 or more, even with Medicaid. Here’s the catch: just because a drug is on the list doesn’t mean you can walk in and get it. Many states require step therapy-you have to try and fail on two cheaper, preferred drugs before they’ll cover the one your doctor originally prescribed. If your doctor wants to prescribe Wellbutrin XL for depression, but you haven’t tried two other SSRIs first? You’ll get denied. Unless you have a rare condition, or your doctor files a prior authorization with clinical notes proving why the cheaper options won’t work.What’s Not Covered? The List Changes Often
Medicaid formularies aren’t static. They change every few months. In North Carolina, for example, drugs like Vasotec, Trulance, and Uceris were removed from the preferred list in 2025 because the state couldn’t get a good enough rebate from the manufacturer. That doesn’t mean they’re banned-but now you need prior authorization just to get them, and even then, approval isn’t guaranteed. Some drugs get moved from preferred to non-preferred status. Epidiolex®, a medication for rare epilepsy syndromes, was moved out of Tier 1 in July 2025. That meant a beneficiary’s monthly copay jumped from $5 to $45. No warning. No notice. Just a formulary update posted online. And then there are drugs that are simply excluded. Over-the-counter painkillers? Not covered. Cosmetics? Nope. Weight-loss drugs like Ozempic? Only if prescribed for diabetes-not for weight loss alone. Even then, prior authorization is almost always required.Prior Authorization: The Hidden Barrier
Prior authorization is the most common reason people delay or skip their meds. It’s when your doctor has to call or submit paperwork to prove your drug is medically necessary. In 2024, the Medicare Rights Center found that 63% of Medicaid beneficiaries waited longer than a week to get approval for a non-preferred drug. Some waited over two weeks. The process is exhausting. Your doctor has to fill out forms, attach lab results, sometimes even write a letter explaining why you can’t use the preferred alternative. If the paperwork is incomplete? Denied. You start over. If you’re on disability, working two jobs, or caring for kids? You don’t have time for this. But here’s the good news: 78% of denials are overturned on appeal-if you submit complete clinical documentation. That means your doctor’s notes need to be specific: not just “patient needs this drug,” but “patient tried Drug A and B, experienced nausea and dizziness, labs show no improvement in HbA1c.” Generic statements won’t cut it.
Costs Are Lower Than You Think-If You Know How to Access Them
Medicaid doesn’t just cover your drugs-it often pays for them at a discount. Thanks to the Medicaid Drug Rebate Program, drugmakers pay the government a cut of every pill sold. That’s how states keep costs down. In 2025, generics made up 89% of all Medicaid prescriptions but only 27% of the total spending. That’s because the rebate system pushes prices way below retail. If you qualify for Extra Help (a federal program for low-income Medicare beneficiaries who also have Medicaid), your out-of-pocket costs drop even further. In 2026, you pay $0 for generic drugs up to $4.90 per prescription and $12.15 for brand names-until you hit $2,000 in annual spending. After that? You pay nothing. And you can change your drug plan once a month, not just once a year. But here’s the problem: 1.2 million eligible people don’t even know they qualify. If you’re on Medicaid, you’re automatically eligible for Extra Help. You don’t need to apply. Yet many don’t get it because no one told them.State-by-State Differences Matter More Than You Realize
North Carolina requires you to fail two preferred drugs before moving to a non-preferred one. Florida? They have a separate list for drugs administered by doctors-like injections for MS or cancer. New York lets you skip step therapy for mental health meds if your doctor says it’s unsafe. Texas has tighter limits on opioid prescriptions. There’s no national standard. Each state negotiates its own deals with pharmacy benefit managers (PBMs) like CVS Caremark, Express Scripts, and OptumRx. That’s why a drug covered in Ohio might be denied in Georgia. It’s not about medical need-it’s about what rebate the state got. If you move states, your coverage can change overnight. That’s why it’s critical to check your state’s current formulary every time you get a new prescription. You can find it on your state’s Medicaid website or through your PBM’s portal.
How to Get Your Prescription Without the Headache
Here’s how to avoid delays and denials:- Always use a network pharmacy. Mail-order is often cheaper for maintenance meds.
- Ask your doctor to check the formulary before prescribing. Many have access to real-time formulary tools.
- If denied, appeal immediately. Keep copies of everything.
- Call your state’s SHIP (State Health Insurance Assistance Program) hotline. They help for free.
- Ask if you qualify for Extra Help-even if you’re on Medicaid, you might not know it.
What’s Coming in 2026?
The federal government is pushing for change. In early 2026, CMS will require states to prove their formularies don’t block medically necessary drugs. That could mean fewer step therapy rules and more transparency. The Inflation Reduction Act’s $2,000 out-of-pocket cap for Medicare Part D also affects dual-eligible patients (those on both Medicare and Medicaid). If you’re one of them, you’ll benefit from lower costs even if your Medicaid plan doesn’t fully cover your drug. But the big threat? New gene therapies. Twelve to fifteen are coming between 2025 and 2027, each costing over $2 million per treatment. States are scrambling. Some are signing outcomes-based contracts-paying only if the drug works. Others are limiting access until they can prove affordability.Bottom Line
Medicaid does cover prescription drugs-but coverage isn’t the same as access. The system works if you know the rules. Use your doctor. Ask questions. Appeal denials. Check your state’s formulary every six months. And if you’re confused, call your state’s SHIP hotline. You’re not alone. Millions of people are navigating the same maze. And with the right info, you can get your meds without the stress.Does Medicaid cover all prescription drugs?
No. Medicaid covers most prescription drugs, but each state has its own formulary-called a Preferred Drug List-that determines which drugs are covered and under what conditions. Some drugs are excluded entirely, and others require prior authorization or step therapy before approval.
Why was my prescription denied by Medicaid?
Common reasons include: the drug isn’t on your state’s formulary, you haven’t tried cheaper alternatives first (step therapy), or your doctor didn’t submit enough clinical documentation. Denials can often be overturned with a proper appeal and detailed medical records from your provider.
How do I find out what drugs Medicaid covers in my state?
Visit your state’s Medicaid website and search for “Preferred Drug List” or “Formulary.” You can also call your state’s State Health Insurance Assistance Program (SHIP) or ask your pharmacy to check your plan’s formulary before filling your prescription.
Can I get my medication cheaper through Extra Help?
Yes-if you qualify. If you have full Medicaid coverage, you’re automatically eligible for Extra Help, which caps your monthly copays at $4.90 for generics and $12.15 for brand-name drugs. After spending $2,000 in a year, you pay $0 for covered drugs. Many people don’t realize they qualify, so check with your state Medicaid office.
Do I have to use a specific pharmacy to get my Medicaid-covered drugs?
Yes. You must use a pharmacy that’s in your Medicaid plan’s network. Many plans encourage or require mail-order for maintenance medications like blood pressure or diabetes drugs, as it’s often cheaper and more convenient. Ask your plan or pharmacist for a list of in-network pharmacies.
How often do Medicaid formularies change?
Formularies are updated at least twice a year-often in January and July-and sometimes more frequently. Some states make off-cycle changes if a drug’s rebate drops or a new generic becomes available. Always check your formulary before starting a new medication.
Are specialty drugs covered under Medicaid?
Yes, but coverage is stricter. Specialty drugs-for conditions like MS, cancer, or rare diseases-are often placed in Tier 3 or higher and require prior authorization, step therapy, and sometimes proof of failure on other treatments. Even then, not all specialty drugs are covered, and some states limit the quantity or duration of use.
What should I do if I can’t afford my Medicaid-covered drug?
First, ask your doctor if there’s a preferred alternative on your state’s formulary. If not, request a prior authorization appeal with clinical documentation. You can also contact your state’s SHIP program for free counseling, or ask your pharmacy about patient assistance programs from drug manufacturers.
