Enrollees who have either a Medicaid card in their possession or an eligibility letter identifying them as a Medicaid beneficiary can purchase prescription medications that are covered by Medicaid.
But before you can just go out and start buying prescription meds through this medical assistance program, you need to know which drugs are covered and where you can purchase them. Only specific pharmacies can take Medicaid and the only way to find out if your favorite pharmacy is on the list, is to contact the pharmacy directly or speak with your Medicaid coverage provider.
In New York, an online list of pharmacies is available. If you go to a pharmacy that isn’t Medicaid preferred, you may not be able to get coverage using your Medicaid health plan or the pharmacy may only be able to provide you with prescriptions that are covered for a short period of time.
As a medical assistance program that’s state-funded, Medicaid provides an important service to beneficiaries in the form of prescription medication coverage.
New York Medicaid adheres to special rules and regulations regarding which drugs may or may not be covered by Medicaid. To help our CDPAP patients better understand Medicaid’s rules and policies governing prescription medication coverage, we’ve put together a summary of Medicaid prescription information below.
Can I use my Medicaid card for prescriptions?
The simple answer is yes, you can use your Medicaid card for prescriptions. New York State offers coverage for many prescription drugs and Medicaid health plans offer cost coverage for these medicines to eligible individuals.
However, even though you can use your Medicaid card at pharmacies to cover the cost of different medications, it’s important to keep in mind that, first of all, only certain medications are covered, and second, some pharmacies may not be a part of the Medicaid preferred provider program.
As long as you have a prescription for a preferred, eligible medication and you’ll be visiting a pharmacy that participates in the Medicaid program, you will be able to use your Medicaid card for prescriptions. If you recently applied for Medicaid but have not received your card yet, you can use your eligibility letter as you would a Medicaid card. This letter works as a form of identification to access the benefits of Medicaid coverage for prescription medications.
How much do prescriptions cost with Medicaid?
The exact way that the cost of prescription medications is calculated for Medicaid is somewhat complex. It’s based on a variety of factors and elements, and so it can be difficult to understand or know the costs of various prescriptions covered by Medicaid. The co-payments on prescriptions drugs are as follows:
● Brand Name Prescription Medications – $3.00
● Generic Prescription Medications – $1.00
● Non-Prescription (Over-the-Counter) Medications – $0.50
The preferred drugs covered by Medicaid in New York are the ones that are most affordable as well as the most functional and effective medications available.
In pricing Medicaid covered prescriptions drugs, a balance must be struck to make it possible for medical establishments and pharmaceutical companies to cover their costs while also maintaining a low enough price that the government can afford to offer almost full coverage of these prescription medications to Medicaid recipients. As such, the costs of prescription drugs are widely variable.
How many prescriptions does Medicaid cover per month?
In different states, the rules and regulations vary in regard to how many Medicaid prescriptions are covered each month. Some states are more liberal than others, and the laws are constantly changing in response to increases or decreases in funding or to the introduction of new medications or treatment modalities.
To fully understand the details and rules around prescription medications and the number of prescriptions that your plan will cover each month, check in with your coverage provider directly.
Depending on which prescription medication you’re taking, the amount of pills you will be able to obtain will vary depending on the drug itself. The New York Medicaid prescription drug formulary lists the preferred Medicaid drugs along with their limits in order to make these limits are clear and concise for both providers and recipients.
Make sure you always check directly with your health plan coverage provider to find out the details about which drugs are covered on your particular plan.
Do all pharmacies take Medicaid?
No, only specific, preferred pharmacies take Medicaid. Just like with doctors, hospitals, and other medical establishments, it’s important to check and see if your chosen pharmacy is on the New York Medicaid preferred pharmacy list.
Quick side note, here is a handy list of different specialists in NYC who accept medicaid:
The best way to check if your pharmacy is on the Medicaid preferred pharmacy list is to either contact the pharmacy directly or to contact your Medicaid coverage provider. It’s essential to ask and clarify because going to a pharmacy that isn’t Medicaid preferred can result in less efficient coverage and use of your Medicaid health plan.
The first place that you can check to see if your pharmacy will take Medicaid is on your coverage plan’s list of preferred providers. In New York, most Medicaid health plans offer an online version of this list that can be accessed at any time as needed.
If your pharmacy that you currently visit is not covered by Medicaid, it may be possible for you to continue visiting that pharmacy and receive Medicaid coverage for a short period of time after you apply. But, after this window of time has passed, it will be necessary to find a Medicaid preferred pharmacy where you can receive adequate coverage for your medications.
How much do Medicaid patients pay for prescriptions?
The amount that Medicaid patients must pay for prescription drugs is variable. This amount changes depending on the type of drug, the specific coverage plan, and whether or not the pharmacy or doctor who prescribed the drug is on the Medicaid list of preferred providers.
For drugs that are not on the preferred prescription list in New York, the co-payment can go up to 20%, while prescription medications that are listed as being preferred medications can cost the Medicaid patient almost nothing at all.
In New York, the co-payment is $3.00 for non-preferred brand name medications and $1.00 for generic drugs, and $0.50 for non-prescription (over-the-counter) medications. Medicaid recipients are required to pay up to $200 in co-payments each year, and if this amount is reached before March 31st of each year you will be exempted from paying co-payments until the next year. Keep in mind that the co-pay year runs from April 1st to March 31st, and that if you pay $200 in co-payments you will be informed via a clearly stated letter.
There are rare cases where drugs that are not on the preferred medication list are allowed to be purchased using Medicaid coverage. In this situation, an appeal must be made that designates the specific reason why that medication is essential to the patient’s health and well-being.
In this case, if a good argument is made the patient can sometimes be granted special privileges and the medication may be covered with Medicaid. The co-payments may also be waived in certain other extenuating circumstances, such as Medicaid recipients who are younger than 21, pregnant, or nursing home residents.
For a list of the New York preferred prescription medications, visit this link: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDL.pdf
Does Medicaid cover over-the-counter drugs?
Medicaid does cover over-the-counter (OTC) drugs if the patient has been given a doctor’s prescription for the drug verbally, in writing, or via an electronic message. In order to be covered, over-the-counter drugs have to be manufactured by a pharmaceutical company that participates in the Federal Drug Rebate Program.
Though OTC medications are covered in the monthly drug benefit limit, all are counted as generics even if a brand-name drug is prescribed (because it costs less than the generic drug). A list of approved drugs is provided at Medicaid.ms.gov.
For Medicaid fee-for service enrollees, the New York State Medicaid Pharmacy program is able to cover FDA-approved and medically necessary prescription or non-prescription drugs. Those who are enrolled in Medicaid Managed Care and Family Health Plus plans are able to directly obtain pharmacy benefits through their managed care plan.
OTC drugs and OTC products that are not included on the Medicaid list of approved drugs may still be covered if the beneficiary is under age 21 and has a “Children’s Medical Necessity” Prior Authorization that’s part of an expanded EPSDT coverage. There are a number of over-the-counter medications that are covered by Medicaid but below are some examples of them:
● Acetaminophen
● Aspirin
● Guifenesin
● Permethrin Lotion
● Pseudoephedrine
● Zinc Oxide Treatment
As a general rule, only generic versions of over-the-counter drugs will be covered by Medicaid, but in certain cases, name-brand medications may be cheaper. When name-brand medications are cheaper, the “Dispense Brand Name Drugs When Less Expensive Initiative” applies.
Medicaid will not cover over-the-counter drugs to prevent pain or treat discomfort or OTC or prescription drugs that are used to treat colds or coughs. And though over-the-counter vitamins are not covered, Medicaid will cover prescribed prenatal vitamins.
Does Medicaid pay for antidepressants medication?
Antidepressant drugs are sometimes covered by Medicaid but there are prescribing restrictions in place in New York that can have an impact on coverage.
The U.S. Medicaid program does pay for certain categories of antidepressants, but their coverage depends on what they’re prescribed to treat. A variety of drugs in the stimulants category can be used to treat depression and some of the drugs listed as antipsychotics or anticonvulsants can also be prescribed to treat Major Depressive Disorder. The antidepressant drug categories that are covered by Medicaid include:
● Tricyclic antidepressants
● Serotonin reuptake inhibitors
● Stimulants
States vary in terms of how they attempt to contain the cost of antidepressants through policy. Lists of preferred drugs, copay systems, prior authorizations policies, doctor and patient education, and drug utilization reviews are all in place to impose limits on antidepressant prescriptions.
● Pregabalin (Lyrica)
● Concerta
Does Medicaid cover anxiety medication?
Adult beneficiaries who are eligible to receive coverage for anxiety medications are identified via the federal Substance Abuse and Mental Health Service Administration (SAMHSA). Medical professionals may provide services through primary, acute, or long-term care using Mental Health primary diagnosis codes or through a record of mental health service provision for elderly patients. Medicaid reimbursements for anxiolytics like benzodiazepines have been decreased through the Triplicate-Prescription Rule. This rule was implemented in New York in 1989 and it requires that the prescribing doctor keep a copy of the patient’s prescription for Schedule IV substances for five years. Two copies of the prescription are sent with the patient to the pharmacist.
Examples of anti-anxiety drugs that are covered by Medicaid include:
● Diazepam
● Topamax
Medicare enrollees with Part A and Part B benefits no longer receive pharmacy benefits through the New York state Medicaid agency unless the drugs are not covered under Medicare Part D. In New York, drug coverage is available for Medicaid beneficiaries who are also Medicare beneficiaries.
Does Medicaid pay for ADHD medication?
If your child has been prescribed ADHD medication, it may be covered by Medicaid however there are policies in place to diminish the use of ADHD drugs among patients who have been diagnosed with the disorder. The National Center on Birth Defects and Developmental Disabilities has developed Medicaid prior authorization intervention policies to help limit the use of ADHD medication.
ADHD medications that may be covered by Medicaid include:
● Ritalin
● Aptensio
● Methylin
● Desoxyn
Because of the prior authorization policies in place for ADHD meds, doctors may recommend that patients try behavioral therapy first.
Does Medicaid cover ED medication?
Viagra is sometimes prescribed as a medical necessity for Erectile Dysfunction (ED) and when this is the case, state law requires that it be covered by Medicaid. However, the current state and federal laws prohibit Medicaid from paying for medications or supplies that treat ED in patients who are registered sex offenders. Managed Care Organizations are expected to police drugs that can be obtained by Medicaid recipients to determine whether or not they are a medical necessity.
Erectile Dysfunction medications that are covered by Medicaid when prescribed as a medical necessity include:
● Sildenafil (Viagra)
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