When you’re on Medicaid, getting your prescriptions shouldn’t feel like a maze. But for many people, it is. Medicaid covers prescription drugs for millions of Americans with low incomes, but what’s actually included-and what’s not-depends on where you live, what drug you need, and even which pharmacy you use. If you’ve ever been told your medication isn’t covered, or had to try three other drugs first before getting the one your doctor prescribed, you’re not alone.
Medicaid Covers Prescriptions-But Not Always the Way You Expect
All 50 states and Washington, D.C., cover outpatient prescription drugs under Medicaid. That’s not optional-it’s standard. But here’s the catch: while federal law says states can cover prescriptions, it doesn’t say which ones. That’s why your coverage in North Carolina might look totally different from someone’s in Florida or Texas.
Medicaid doesn’t just hand out any drug you ask for. Instead, each state creates a Preferred Drug List (PDL), also called a formulary. This list sorts medications into tiers, like a pricing ladder. Tier 1 is usually generic drugs-cheap, effective, and preferred. Tier 2 is brand-name drugs with higher copays. Tier 3 or 4? That’s where specialty drugs live: expensive, high-cost treatments for conditions like cancer, rheumatoid arthritis, or hepatitis C.
For example, in North Carolina, a generic blood pressure pill might cost you $4.90. But if you need a brand-name version of the same drug, your copay could jump to $12.15. And if it’s a specialty drug? You could be looking at hundreds-even thousands-of dollars unless you qualify for extra help.
Step Therapy: Why You Might Have to Fail First
One of the most frustrating parts of Medicaid pharmacy coverage is something called step therapy, or "trial and failure." It means you can’t get the drug your doctor prescribed unless you’ve tried-and failed-two other, cheaper drugs first.
Thirty-eight states, including North Carolina, require this for most therapeutic classes. So if your doctor prescribes Wellbutrin XL for depression, but Medicaid’s formulary lists two other SSRIs as preferred, you’ll have to try those first. If they don’t work-or cause bad side effects-you then submit paperwork proving it. That process can take weeks.
Reddit users in the r/Medicaid community report this is especially common for mental health and chronic pain medications. One person wrote in October 2025: "I had to fail on three antidepressants before they approved my original prescription. I was suicidal by the time they said yes."
There are exceptions. If there’s only one preferred drug in a class, or if your condition is rare, or if your doctor provides detailed clinical notes showing why other drugs won’t work, you might skip the step therapy. But getting those notes approved? That’s where prior authorization comes in.
Prior Authorization: The Paperwork Hurdle
Prior authorization is when Medicaid needs your doctor to prove your drug is medically necessary before they’ll pay for it. It’s not just a form-it’s often a full clinical summary, lab results, or even a letter explaining why cheaper options failed.
In North Carolina, prior authorizations for insulin used by Type 1 diabetics can be approved for up to three years-if the right documentation is submitted. But for other drugs, like the now-removed Trulance or Uceris, coverage was cut entirely because the manufacturer stopped offering a rebate. No rebate? No coverage.
According to the Medicare Rights Center’s 2024 survey, 63% of Medicaid beneficiaries faced delays because of prior authorization. On average, it took 7.2 business days just to get an initial decision. If you had to appeal? That jumped to 14.5 days. And during that time, you might go without your medication.
But here’s the good news: 78% of denied requests were overturned when the doctor included full clinical documentation. That means your doctor’s notes aren’t just paperwork-they’re your lifeline.
Costs: Copays, Deductibles, and the Extra Help Program
How much you pay out of pocket depends on your income and whether you qualify for Extra Help (also called the Low-Income Subsidy). If you get full Medicaid coverage, you’re automatically eligible for Extra Help, but most people don’t know that.
Here’s what Extra Help covers in 2025:
- $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 everything else.
That’s a game-changer. The Medicare Rights Center found that 89% of people on Extra Help were satisfied with their drug costs-compared to just 42% of those without it.
But here’s the problem: about 1.2 million people who qualify for Extra Help aren’t enrolled. They think they don’t qualify, or they don’t know how to apply. If you’re on Medicaid, you already qualify. You just need to ask.
What’s Not Covered? The List Keeps Changing
Medicaid formularies aren’t static. They change every few months. In North Carolina’s October 2025 update, nine drugs were removed from coverage entirely: Vasotec, Acanya, Diastat, Relistor, Trulance, Vanos, Bryhali, Solodyn ER, Fenoglide, Apriso, Colazal, Uceris, and Uceris Rectal Foam. Why? They no longer offered a rebate to the state.
Even more surprising? Epidiolex®, a life-changing medication for rare forms of epilepsy, was moved from "Preferred" to "Non-preferred" status in July 2025. That means higher copays and stricter prior authorization.
States remove drugs for one reason: money. The Medicaid Drug Rebate Program requires drugmakers to pay rebates to states in exchange for being on the formulary. If a company stops offering a rebate-or offers too small a one-the state drops it.
That’s why you can’t assume your drug will be covered next year. Always check your state’s current formulary before filling a prescription.
Network Pharmacies and Mail-Order Rules
You can’t just walk into any pharmacy and expect Medicaid to pay. You have to use a network pharmacy. CVS, Walgreens, Rite Aid, and local independent pharmacies are usually in-network-but not always. Some states require you to use mail-order for maintenance medications like blood pressure or diabetes drugs.
In North Carolina, if you’re on a long-term medication, you might be pushed toward mail-order services. It’s cheaper for the state, and you get a 90-day supply instead of 30. But if you’re not set up for it, you’ll get denied at the counter.
And if you’re using a pharmacy that doesn’t accept Medicaid? You’ll pay full price-and get no reimbursement later.
How to Navigate This System
Here’s what works:
- Check your state’s current formulary every 3-6 months. They update often.
- Ask your doctor to submit prior authorization paperwork before you go to the pharmacy.
- If your drug is denied, appeal-with your doctor’s clinical notes attached.
- Ask if you qualify for Extra Help. If you’re on Medicaid, you do.
- Use in-network pharmacies. Call ahead if you’re unsure.
- Call your State Health Insurance Assistance Program (SHIP). They help for free.
SHIP counselors say the top three questions they get are: "Why isn’t my drug covered?", "How do I get prior authorization?", and "Which pharmacy accepts Medicaid?" They handle 64% of all pharmacy-related calls in Q3 2025.
What’s Changing in 2026?
The federal government is stepping in. In September 2025, CMS Administrator Chiquita Brooks-LaSure announced new rules coming in Q1 2026: states must prove their formulary restrictions don’t create "unreasonable barriers" to care. That could mean fewer step therapy rules and faster prior authorizations.
Also, the Federal Upper Limit (FUL) for generics might change. Right now, it’s set at 250% of the average manufacturer price minus 17.1%. But MedPAC recommends lowering it to 225%-which could save Medicaid $1.2 billion a year and possibly lower copays.
And with 12-15 new gene therapies expected to hit the market between 2025 and 2027-each costing over $2 million-states are scrambling to find ways to pay for them without breaking budgets. Some are testing outcome-based contracts: pay only if the drug works.
It’s not perfect. But Medicaid is evolving. And if you know how to use it, you can get the drugs you need-even when the system feels stacked against you.
Does Medicaid cover all prescription drugs?
No. Medicaid covers most prescription drugs, but each state creates its own list called a Preferred Drug List (PDL). Some drugs are excluded because the manufacturer doesn’t offer a rebate, or because they’re too expensive. Always check your state’s current formulary before filling a prescription.
Why do I have to try other drugs before getting the one my doctor prescribed?
This is called step therapy or "trial and failure." It’s a cost-control tool used by 38 states. Medicaid requires you to try cheaper, preferred drugs first. If they don’t work or cause side effects, your doctor can submit documentation to request coverage for the original drug. You can appeal if denied.
How much will I pay for my prescriptions under Medicaid?
It depends. For most people, copays are $4.90 for generics and $12.15 for brand-name drugs. If you qualify for Extra Help (which you do if you have full Medicaid), you pay no more than $2,000 per year for all prescriptions. After that, your drugs are free. Some states have no copays at all for certain groups like children or pregnant women.
Can I use any pharmacy with Medicaid?
No. You must use a pharmacy in your state’s Medicaid network. Some states require you to use mail-order for long-term medications. Always confirm your pharmacy accepts Medicaid before you go. If you don’t, you’ll pay full price and won’t be reimbursed.
What if my drug is removed from the formulary?
If your drug is removed, your state will notify you and your doctor. You may be able to get it through a prior authorization if you can prove medical necessity. Otherwise, your doctor can switch you to a similar drug on the formulary. Don’t stop taking your medication-call your pharmacy or SHIP counselor right away.
How do I know if I qualify for Extra Help?
If you have full Medicaid coverage, you automatically qualify for Extra Help. You don’t need to apply separately. This gives you lower copays and a $2,000 annual out-of-pocket cap. If you’re unsure, call your state’s Medicaid office or visit Medicare.gov/ExtraHelp.
Can I change my prescription plan anytime?
Yes. Starting in 2025, Medicaid and Extra Help beneficiaries can change their drug coverage once per month-not just during a limited enrollment period. This gives you more flexibility if your needs change or your drug gets removed from the formulary.
Neelam Kumari
December 11, 2025 AT 19:58Wow. So Medicaid’s just a corporate bargaining chip now? Drugs get dropped because some pharma exec decided to stop paying kickbacks? Of course they do. Welcome to healthcare in 2025 - where your life is priced in rebates.
Doris Lee
December 12, 2025 AT 00:04I got my insulin covered after two appeals and a letter from my endocrinologist. It took 11 days but I’m alive. Don’t give up. Your doctor’s notes matter more than you think.
Taylor Dressler
December 13, 2025 AT 16:26Just a quick note for anyone confused about Extra Help: if you’re on full Medicaid, you’re automatically enrolled. No application needed. Call your state’s Medicaid office and ask for confirmation - most people don’t know this and end up overpaying. It’s not a perk, it’s your right.
Nikki Smellie
December 13, 2025 AT 23:08They’re not removing drugs because of rebates... they’re removing them because the government is quietly privatizing healthcare. Look at the timeline: right after the new private insurers got their contracts signed. Coincidence? I think not. 🤔
Stephanie Maillet
December 14, 2025 AT 10:48It’s strange, isn’t it? We have the technology, the science, the drugs - but we’re still stuck in a system that treats medicine like a commodity instead of a human right? We’ve built rockets to Mars, yet we can’t make sure someone with diabetes gets their insulin without jumping through a thousand hoops. What does that say about us? I wonder…
Michaux Hyatt
December 15, 2025 AT 06:21Step therapy is brutal - I had to fail on two SSRIs before they approved my original one for anxiety. Took three months. By then, I was a shell. But when I finally got the right med? Life changed. If you’re going through this - keep the logs, keep the notes, and don’t let them gaslight you into thinking you’re "overreacting."
Courtney Blake
December 15, 2025 AT 10:40Why are we even surprised? America spends more on healthcare than any country - and still can’t get its act together. It’s not broken. It’s designed this way. The system isn’t failing - it’s succeeding at extracting profit from desperation.
Queenie Chan
December 15, 2025 AT 13:06I’m from Canada, and I’ll be honest - I read this and felt physically ill. We have our own messes, but at least we don’t make people beg for the drugs their bodies need. You’re not just fighting bureaucracy - you’re fighting a system that sees your illness as a line item. That’s not healthcare. That’s cruelty dressed in policy.
Ariel Nichole
December 15, 2025 AT 17:16Big shoutout to SHIP counselors - they saved my mom’s life last year when her drug got pulled. Free, patient, and actually know what they’re talking about. If you’re stuck, call them. No shame. They’re the real heroes.
Raj Rsvpraj
December 17, 2025 AT 00:20Of course the U.S. can’t afford to cover everything - we’re not some socialist utopia. If you want your expensive gene therapy covered, maybe don’t live in a country that lets people go bankrupt from medical bills. Get rich. Or move to Switzerland. Problem solved.