Medicaid Coverage for Prescription Medications: What’s Included in 2025

When you’re on Medicaid, getting your prescriptions shouldn’t be a financial crisis-but knowing what’s covered, what’s not, and how to get it can feel like navigating a maze. In 2025, every state covers outpatient prescription drugs for Medicaid enrollees, but Medicaid coverage for prescription medications isn’t the same from North Carolina to Florida to California. What’s a $5 generic in one state might require a 30-day waiting period and three doctor’s notes in another.

What’s Always Covered? The Basics of Medicaid Pharmacy Benefits

All 50 states and D.C. provide prescription drug coverage under Medicaid, thanks to a federal requirement that’s been in place since 1990. It’s not optional anymore-every state has made it mandatory because it’s too critical to leave out. But here’s the catch: while all states cover drugs, they don’t all cover the same ones. Medicaid doesn’t have one big list of approved medications. Instead, each state builds its own Preferred Drug List (PDL), which decides which drugs are easy to get and which are hard.

Most formularies are split into tiers. Tier 1 is usually generics-drugs like metformin, lisinopril, or levothyroxine. These cost you $1 to $5 per 30-day supply. Tier 2 is brand-name drugs that don’t have a generic yet, like Humira or Ozempic. These can cost $20 to $50. Some states have a Tier 3 for specialty drugs-things like cancer treatments or hepatitis C cures. Those can cost hundreds, even if Medicaid picks up most of the bill.

You also get access to mail-order pharmacies for maintenance meds like blood pressure pills or diabetes drugs. Many states require you to use them for 90-day supplies to save money. If you pick up your meds at a local pharmacy that’s not in your state’s network, you might pay full price and never get reimbursed.

Why You Might Be Denied a Prescription (Even If It’s Prescribed)

Just because your doctor wrote a prescription doesn’t mean Medicaid will pay for it. Two big roadblocks stand between you and your meds: step therapy and prior authorization.

Step therapy-also called “trial and failure”-means you have to try two or three cheaper, preferred drugs first before Medicaid will cover the one your doctor actually wants. In North Carolina, for example, if you have depression and your doctor prescribes Wellbutrin XL, you might need to try two other SSRIs first, even if you already tried them and they didn’t work. If you’re on insulin and your doctor wants you on a newer premixed combo, you might need to fail two older insulins before approval. This isn’t about cost-cutting for fun-it’s built into federal law to push states toward lower-cost options. But it’s also a real barrier. A 2024 survey found 63% of Medicaid users had to wait weeks to get meds because of this rule.

Prior authorization is another hurdle. For drugs like opioids, certain mental health meds, or high-cost biologics, your doctor has to submit paperwork proving why you need it. That means medical records, lab results, and sometimes even a letter explaining why cheaper options failed. The average approval time? Seven business days. If it gets denied and you appeal, it can take two weeks longer. And if your doctor’s office is understaffed? You might wait a month.

How States Decide What’s on the List-and What Gets Removed

States update their formularies all the time. North Carolina’s Medicaid PDL changed in July and October 2025 alone. Some drugs were removed entirely: Vasotec, Trulance, Relistor, and Uceris are no longer covered because the manufacturer stopped offering the required rebate. Others were moved from preferred to non-preferred-like Epidiolex, a seizure medication for children. That doesn’t mean it’s banned. It just means you’ll pay more, and you’ll need prior authorization.

The reason? Money. The Medicaid Drug Rebate Program forces drugmakers to pay back a percentage of the price to the state. If a drug’s rebate drops below a certain level, the state drops it. It’s not about safety. It’s not about effectiveness. It’s about whether the company is still willing to play by the state’s pricing rules.

States also use the Federal Upper Limit (FUL) to cap what they’ll pay for generics. The FUL is calculated at 250% of the average manufacturer price, minus 17.1%. That number changes every quarter. If a generic drug’s price jumps above that limit, Medicaid won’t cover it unless the pharmacy absorbs the difference-which they usually won’t. So you might see your $4 generic suddenly disappear from the shelf.

Who Pays What? Copays, Deductibles, and Extra Help

Most Medicaid enrollees pay nothing or next to nothing for prescriptions. In most states, generic copays are $1-$5, brand-name are $5-$15. Some states have no copays at all. But there’s a hidden layer: Extra Help.

If you qualify for full Medicaid coverage, you automatically qualify for Extra Help (also called the Low-Income Subsidy) for Medicare Part D if you’re also on Medicare. That means: $0 premium, $0 deductible, $4.90 for generics, $12.15 for brands-until you hit $2,000 in total drug costs for the year. After that? You pay $0. That’s a lifesaver for people on multiple medications. But here’s the shocker: 1.2 million people who qualify for Extra Help don’t even know they’re eligible. They’re paying full price because no one told them.

Dual-eligible beneficiaries-people on both Medicare and Medicaid-are the biggest users of high-cost drugs. They make up only 15% of Medicaid pharmacy users but account for 38% of spending. That’s because they’re often older, managing diabetes, heart disease, and arthritis-all with expensive meds. Medicaid covers what Medicare doesn’t, but the system is complicated. You need to know which plan pays for what, when, and how.

What’s Not Covered? The Hidden Gaps

Medicaid doesn’t cover everything. Here’s what’s often excluded:

• Drugs for weight loss (like Wegovy or Ozempic for obesity, unless used for diabetes)
• Over-the-counter meds (even if prescribed)
• Drugs for cosmetic purposes (like hair growth treatments)
• Sexual dysfunction drugs (like Viagra or Cialis)
• Some fertility treatments
• Drugs not approved by the FDA

And even if a drug is covered, it might only be covered under strict conditions. For example, a drug for multiple sclerosis might require proof that you’ve tried two other drugs first. Or you might need to be diagnosed with a specific subtype of the disease.

How to Get the Meds You Need-Without the Headache

If you’re on Medicaid, here’s how to cut through the red tape:

1. Check your state’s current Preferred Drug List. Go to your Medicaid website or call your state’s pharmacy help line. Don’t rely on last year’s list.
2. Ask your doctor if the prescribed drug is on Tier 1. If it’s not, ask if there’s a similar drug that is.
3. If you’re denied, ask for the denial letter. It’ll tell you why-and what you need to appeal.
4. Get your doctor to write a letter of medical necessity. Include specific details: what you tried, what failed, what side effects you had.
5. Use mail-order for maintenance meds. It’s cheaper and often faster.
6. Make sure your pharmacy is in-network. Call your insurer’s customer service to confirm.
7. Apply for Extra Help if you’re on Medicare too. It’s automatic if you have full Medicaid, but you still have to apply.

What’s Changing in 2025 and Beyond

In 2025, things are shifting fast. The Inflation Reduction Act capped Medicare Part D out-of-pocket costs at $2,000 per year-but that doesn’t help Medicaid-only enrollees. However, CMS announced new rules in September 2025 requiring states to prove their formularies don’t block medically necessary care. That could mean fewer step therapy rules in the future.

Also, 22 states are now testing new payment models for gene therapies-drugs that cost over $2 million per dose. These programs pay the drugmaker only if the treatment works. It’s still early, but it could change how high-cost drugs are covered long-term.

Meanwhile, generic drug prices keep rising. The Federal Upper Limit might be lowered from 250% to 225% of the average manufacturer price. That could save Medicaid $1.2 billion a year-but might also mean fewer generics stay on the formulary.

Real Stories, Real Struggles

One user in Raleigh, NC, spent six weeks trying to get a new antidepressant after her two preferred SSRIs made her suicidal. Her doctor wrote the letter. She filed the appeal. It took 18 days. She got approved-but missed three weeks of work.

Another in Florida couldn’t get her insulin because her plan said she needed to try a different brand first. She ran out. She went to the ER. Her bill: $1,200. Medicaid paid it-but she still lost two days of work and her anxiety spiked.

These aren’t rare cases. They’re everyday realities for millions.