When you’re on Medicaid, getting your prescriptions shouldn’t feel like a maze. But for many people, it is. Even though Medicaid covers prescription drugs in every state, what’s actually covered, how much you pay, and how you get it can vary wildly depending on where you live. If you’ve ever been told your medication isn’t on the list, or had to try three other drugs first before getting the one your doctor prescribed, you’re not alone. Here’s what’s really included in Medicaid prescription coverage in 2025 - and what’s not.
Medicaid Covers Prescriptions - But Not All of Them
Medicaid is required to cover outpatient prescription drugs for nearly all enrollees. That’s not optional - every state provides it. But that doesn’t mean every single drug is covered. States build their own Preferred Drug Lists (PDLs), which act like a filter. These lists decide which medications are preferred (cheaper and easier to get) and which are non-preferred (harder to access, often requiring extra steps).
For example, in North Carolina, a generic blood pressure pill might be on Tier 1 - meaning you pay $5 or less. But if your doctor prescribes a brand-name version of the same drug, it’s likely on Tier 2, and you’ll pay $30 or more. Some drugs aren’t on the list at all. In October 2025, North Carolina removed drugs like Trulance, Uceris, and Relistor from coverage because they no longer qualified for federal rebates. That means even if your doctor says you need it, Medicaid won’t pay unless you get special approval - and even then, it’s not guaranteed.
Tiered Formularies: How Much You Pay Depends on the Tier
Almost every state uses a tiered system for prescription drugs. Think of it like a pricing ladder:
- Tier 1: Generic drugs. Lowest cost. Usually $0-$5 copay.
- Tier 2: Preferred brand-name drugs. Moderate cost. Usually $10-$30 copay.
- Tier 3: Non-preferred brand-name drugs. Higher cost. Often $40-$60 or more.
- Tier 4: Specialty drugs. High-cost medications for complex conditions like cancer, MS, or hepatitis C. Copays can be $100+ or a percentage of the drug’s total price.
Generic drugs make up 89% of all Medicaid prescriptions - but only 27% of the total spending. Why? Because they’re cheap. Specialty drugs, which only account for 3% of prescriptions, make up 42% of Medicaid’s drug spending. That’s why states are so strict about who gets them.
Step Therapy: You Have to Try Cheaper Drugs First
Step therapy - also called “trial and failure” - is one of the biggest roadblocks. In 38 states, including North Carolina and Florida, you must try and fail on at least two preferred drugs before Medicaid will pay for the one your doctor originally prescribed.
Let’s say you have depression and your doctor wants to prescribe Wellbutrin XL. But Wellbutrin isn’t on Tier 1 or 2. Medicaid will make you try two other antidepressants first - like sertraline or escitalopram. If those don’t work, or cause bad side effects, your doctor must submit paperwork proving why they failed. Only then will Medicaid approve Wellbutrin. This process can take days or weeks. A 2024 survey found that 63% of Medicaid beneficiaries experienced delays because of step therapy.
There are exceptions. If there’s only one drug in a class, or if your condition is urgent (like a recent cancer diagnosis), you can skip this step. But proving that often means your doctor has to write a detailed letter - and not all clinics have the time or resources to do it.
Prior Authorization: The Paperwork Hurdle
Even if a drug is on the formulary, you might still need prior authorization. This means your doctor has to ask Medicaid for permission before the pharmacy can fill it. It’s common for drugs like insulin pens, mental health medications, and rheumatoid arthritis biologics.
In North Carolina, prior authorizations for premixed insulin in Type 1 Diabetes patients can be approved for up to three years - if the right documentation is submitted. But for other drugs, the approval window might be just 30 days. And if the paperwork is incomplete? The pharmacy won’t fill it. No second chances.
Here’s the good news: 78% of denied prior authorizations are overturned on appeal - if you submit complete medical records. That means if you get denied, don’t give up. Ask your doctor to resubmit with detailed notes about your condition, previous treatment failures, and why the requested drug is medically necessary.
What About Costs? Copays, Deductibles, and Extra Help
Medicaid doesn’t have a deductible for prescriptions. Your out-of-pocket cost is just the copay - and it’s capped. In most states, generic drugs cost $0-$5. Brand-name drugs are $10-$30. Specialty drugs vary but are often capped at $50-$100 per fill.
But there’s a secret weapon: Extra Help. If you get full Medicaid coverage, you automatically qualify for Extra Help - a federal program that lowers Medicare Part D drug costs. In 2025, that means:
- $0 monthly premium
- $0 deductible
- $4.90 copay for generics
- $12.15 copay for brand-name drugs
- Once you hit $2,000 in total drug costs for the year, you pay $0 for the rest
And here’s the kicker: about 1.2 million people who qualify for Extra Help don’t even know it. If you’re on Medicaid, you’re already eligible. You don’t need to apply separately. Just ask your pharmacist or call your state’s SHIP (State Health Insurance Assistance Program) hotline.
Network Pharmacies and Mail Order
You can’t just walk into any pharmacy. Medicaid works with specific networks. CVS Caremark, Express Scripts, and OptumRx manage pharmacy benefits for most states. If you go to a non-partner pharmacy, you’ll pay full price - and Medicaid won’t reimburse you.
For maintenance medications (like blood pressure pills or diabetes drugs), many states require you to use mail-order services. You’ll get a 90-day supply shipped to your home, often at a lower cost. It’s convenient - but you need to plan ahead. Running out? You’ll have to wait days for a refill.
State-by-State Differences Matter
There are 50 different Medicaid programs. What’s covered in Florida isn’t the same as in North Carolina. Florida has a separate Quick Reference Guide for physician-administered drugs - things like injections given at a clinic. North Carolina removed 12 drugs from its formulary in 2025. Some states allow one step therapy trial; others require two. Some allow exceptions for mental health; others don’t.
There’s no national standard. That’s why knowing your state’s current Preferred Drug List is critical. You can find yours on your state’s Medicaid website - or ask your pharmacist. Don’t assume your coverage from last year is still the same. Formularies change every quarter.
What’s Changing in 2025 and Beyond
The Inflation Reduction Act capped Medicare Part D out-of-pocket costs at $2,000 per year starting in 2025. That helps dual-eligible people (those on both Medicare and Medicaid) - but doesn’t change Medicaid’s own rules. Still, it’s one less financial worry.
Also in 2025, Medicaid beneficiaries can now change their drug coverage once a month - not just during the annual enrollment period. That’s huge. If a drug stops working or becomes too expensive, you can switch faster.
Looking ahead, CMS is planning new rules in early 2026 to make sure state formularies don’t block access to medically necessary drugs. And with 12-15 new gene therapies expected to hit the market by 2027 - each costing over $2 million - states are scrambling to find ways to pay for them without bankrupting their budgets. Value-based contracts are growing: if a drug doesn’t work, the manufacturer pays back part of the cost.
What You Can Do Right Now
Don’t wait for a problem to happen. Here’s how to take control:
- Find your state’s current Preferred Drug List. Search “[Your State] Medicaid Preferred Drug List 2025.”
- Check if your meds are on it. Look up your drug by name - not brand, not generic. Use the exact spelling.
- Ask your pharmacist. They know the formulary better than you do. Ask: “Is this on the list? Do I need prior auth?”
- Ask about Extra Help. If you’re on Medicaid, you’re already eligible. Confirm with your state’s SHIP hotline.
- Keep records. Save every denial letter. Keep copies of your doctor’s notes. You’ll need them if you appeal.
Medicaid prescription coverage is complex - but it’s designed to work for you. You just have to know how to navigate it. The system isn’t perfect. But with the right info, you can get the meds you need without the stress.
Does Medicaid cover all prescription drugs?
No. Medicaid covers outpatient prescription drugs in every state, but each state creates its own list of covered medications called a Preferred Drug List (PDL). Some drugs are excluded due to cost, lack of rebate eligibility, or policy changes. Always check your state’s current formulary.
Why do I have to try other drugs before getting the one my doctor prescribed?
This is called step therapy or trial and failure. States use it to control costs by requiring you to try lower-cost, preferred drugs first. In 38 states, you must fail two preferred drugs before Medicaid will cover a non-preferred one. Exceptions exist for urgent cases or if only one drug is available in a class.
How much will I pay for my prescriptions on Medicaid?
Copays vary by tier and state. Generics usually cost $0-$5, preferred brands $10-$30, and non-preferred or specialty drugs can be $40-$100+. Many states cap specialty drug copays. If you qualify for Extra Help, your costs drop further - to $4.90 for generics and $12.15 for brands.
Can I use any pharmacy with Medicaid?
No. You must use pharmacies in your state’s Medicaid network - typically managed by PBMs like CVS Caremark or OptumRx. Using an out-of-network pharmacy means you pay full price and won’t get reimbursed. Always confirm your pharmacy is in-network before filling a prescription.
What is Extra Help, and do I qualify?
Extra Help is a federal program that reduces Medicare Part D drug costs. If you have full Medicaid coverage, you automatically qualify. Benefits include $0 premiums, $0 deductibles, $4.90 copays for generics, and $12.15 for brand-name drugs. After spending $2,000 in a year, you pay $0 for covered drugs. Many eligible people don’t know they qualify - ask your pharmacist or state SHIP hotline.
What should I do if my prescription is denied?
Don’t accept the denial. Ask your doctor to submit a prior authorization appeal with detailed clinical documentation showing why the requested drug is medically necessary. About 78% of denials are overturned on appeal when proper records are provided. Keep copies of all paperwork and follow up in writing.
Do Medicaid formularies change often?
Yes. Most states update their Preferred Drug Lists quarterly. North Carolina, for example, made changes in July and October 2025. Some drugs are removed due to lost rebates; others move tiers. Always check your state’s website before filling a new prescription - what was covered last month may not be covered today.
Knowing your rights and your state’s rules is the best way to avoid surprises. Medicaid is meant to help - but you have to be your own advocate.
There are 14 Comments
Olanrewaju Jeph
Medicaid's formulary changes are a nightmare, but knowing your state's PDL is half the battle. I check mine every quarter-last month, my generic metformin moved from Tier 1 to Tier 2. Called my pharmacist, they confirmed it, and I switched to a different brand that's still covered. Small win, but it matters.
Pro tip: Save every denial letter. I have a folder labeled 'Medicaid Battles'-it saved me when I appealed a denied insulin pen last year.
Dalton Adams
Let’s be real-this entire system is a joke. Medicaid’s ‘step therapy’ is just bureaucratic cruelty disguised as cost control. I had a friend with MS who had to fail on three generics before getting her actual drug. She ended up in the ER because she couldn’t wait six weeks. And now we’re supposed to be impressed that 78% of denials get overturned? That’s not a feature-it’s a bug.
Also, ‘Extra Help’? That’s just Medicare Part D’s leftovers. If you’re on Medicaid, you’re already poor. Why should you need a federal ‘help’ program just to get your diabetes meds? We need universal coverage, not a patchwork of loopholes. 😤
Kane Ren
You got this. I know it feels overwhelming, but you’re not alone. I was terrified when my antidepressant got pulled last year, but I reached out to my state’s SHIP hotline-and they walked me through the appeal step by step. It took three weeks, but I got my prescription back.
Don’t give up. Ask for help. Pharmacists, social workers, even Reddit threads like this one-they all want you to succeed. You’re doing better than you think.
Charmaine Barcelon
So... you’re telling me... that if your doctor prescribes something... and it’s not on the list... you have to... fail on two others... first? And then... hope... that the paperwork... gets processed... before your meds run out? That’s not healthcare. That’s a game of Russian roulette... with your life... and your sanity... and your bank account.
Karla Morales
📊 Data point: In 2024, 63% of Medicaid beneficiaries experienced delays due to step therapy. That’s 1 in 1.6 people. And yet, states continue to expand these policies. Why? Because pharmaceutical rebates incentivize formulary exclusion. The real villain isn’t the bureaucracy-it’s the rebate structure. Value-based contracts are a step forward, but they’re still profit-driven. We need price caps, not paperwork.
Also, mail-order? 90-day supply? What if you’re homeless? What if you don’t have a stable address? 🤔
Javier Rain
Hey, I just want to say-this post is gold. Seriously. I’ve been fighting with my state’s Medicaid for months over my RA meds. I finally found my PDL online, checked my drug, and saw it was Tier 3. I called my pharmacist, asked about prior auth, and they helped me fill out the form. Got approved in 48 hours.
Don’t let the system beat you. Use the tools. Ask questions. Keep pushing. You’re not crazy for being frustrated-you’re just paying attention. Keep going.
Laurie Sala
I cried when they took my dad’s Relistor off the list. He’s been on it for five years. The doctor said it was ‘not cost-effective.’ Cost-effective? He’s 78. He can’t walk without it. I spent three weeks writing letters, calling Medicaid, begging. They finally approved it... after he was in the hospital for three days.
Why does someone’s dignity have to be tied to a rebate calculation? Why does it take a crisis to get care? I’m exhausted. I’m so, so tired.
Lisa Detanna
I’m from Puerto Rico, and I’ve seen how Medicaid works differently here. We don’t have tiered formularies the same way. But we have other problems-like pharmacies that don’t stock meds because they’re not profitable. I get what you’re saying about state-by-state chaos. It’s not just North Carolina or Florida-it’s everywhere. We need a national standard. Not because it’s easy-but because people’s lives depend on it.
And yes, Extra Help? I didn’t know I qualified until my cousin told me. We need more outreach. Not more paperwork.
Demi-Louise Brown
Check your state’s Preferred Drug List. Do it now. Don’t wait for a denial. It takes five minutes. Search “[Your State] Medicaid PDL 2025.”
Save your doctor’s notes. Keep a folder. Ask your pharmacist. You’re not being difficult. You’re being smart.
And if you’re on Medicaid-you already qualify for Extra Help. No application needed. Just ask.
Matthew Mahar
so i just found out my insulin is now tier 3?? like... i thought it was covered?? i went to the pharmacy and they said nope, need prior auth... so i called my doc and they said they'll send it but it'll take 3-5 days?? i'm out of insulin today. what do i do?? someone please help. i'm scared.
John Mackaill
There’s a quiet resilience in people who navigate these systems daily. I’ve seen it in my community-mothers choosing between food and meds, elderly men walking miles to a network pharmacy because their bus doesn’t go to the one with their prescription.
It’s not about policy. It’s about dignity. The real reform isn’t tweaking tiers or expanding mail-order. It’s recognizing that healthcare isn’t a privilege to be rationed-it’s a right to be guaranteed.
Adrian Rios
Let me break this down for anyone who’s overwhelmed: Step therapy? That’s when the system says, ‘Try cheaper drugs first.’ But what if those cheaper drugs made you sicker? What if they caused anxiety, weight gain, or suicidal ideation? Your doctor isn’t just prescribing a pill-they’re prescribing safety, stability, survival.
And prior authorization? It’s not ‘paperwork.’ It’s a barrier designed to make you give up. But you don’t have to. You can appeal. You can fight. You can ask for help. And you deserve to get your meds without begging for them.
Here’s what I did: I printed out my entire medical history, highlighted every failed trial, and handed it to my pharmacist. They filed the appeal for me. Took 11 days. Approved. I got my drug. I cried.
You’re not alone. And you’re not asking too much. You’re asking for what you’re owed.
Casper van Hoof
The structure of Medicaid formularies reflects a deeper epistemological tension: between utilitarian cost-efficiency and deontological medical necessity. The state, as agent of the social contract, is obligated to provide care-but is constrained by fiscal realism. The PDL is not merely a list; it is a moral calculus, where the value of a human life is implicitly weighed against the marginal cost of a biologic.
One might argue that the tiered system is a necessary evil. But one must also ask: When does necessity become cruelty? When does pragmatism become dehumanization?
And yet, the existence of Extra Help, and the 78% appeal success rate, suggests that the system, however flawed, still contains within it the seeds of justice-if only one has the will to invoke it.
Richard Wöhrl
Important note: If you’re on Medicaid and you’re on Medicare too (dual-eligible), you’re automatically enrolled in Extra Help-no application needed. But many people don’t know that. I’ve worked with dozens of seniors who thought they had to sign up separately. They didn’t. They just needed someone to tell them.
Also: If your drug was removed from the formulary, ask your doctor if there’s a therapeutic equivalent that’s still covered. Sometimes, a different brand or manufacturer is still on the list. And always, always keep copies of every denial letter. I’ve seen people get approved on the third appeal because they had the paperwork.
You’re not being difficult. You’re being a patient advocate. Keep going.
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