Medicaid, the federal-state program providing health coverage to over 80 million low-income Americans, typically includes prescription drug benefits, but coverage varies by state, age, and drug type. In 2025, Medicaid prescription coverage is mandatory for children and optional for adults, with states managing formularies (lists of covered drugs) and copays.
The “One Big Beautiful Bill” (signed July 4, 2025) introduces $1 trillion in cuts through 2034, potentially increasing copays or limiting formularies in some states. This blog explores if Medicaid covers prescriptions for adults and children, what drugs are included, costs, state rules, and how to apply. For eligibility, use the Medicaid Eligibility Calculator. Compare with Medicare at Difference Between Medicare and Medicaid.
Does Medicaid Cover Prescriptions for Adults?
Yes, Medicaid covers prescriptions for adults in all 50 states and D.C., but coverage levels vary. Since the ACA, states must provide prescription drugs as an essential benefit for expansion adults (up to 138% FPL), but traditional Medicaid adults (e.g., disabled, low-income parents) may have limited formularies.
Adult Prescription Coverage
- Mandatory Benefit: States cover FDA-approved drugs, but may require prior authorization (PA) for expensive or non-preferred medications.
- Formularies: States use Preferred Drug Lists (PDLs); preferred drugs have low or no copays, while non-preferred require PA or higher costs.
- Limits: Some states cap prescriptions (e.g., 3–5/month in Florida, Texas), with exceptions for chronic conditions.
- Specialty Drugs: Covered for conditions like HIV, cancer, or hepatitis C, but PA often required.
- Over-the-Counter (OTC): Covered if prescribed (e.g., pain relievers, vitamins in some states).
In non-expansion states (e.g., Texas), adults qualify only if disabled or parents, with coverage similar but stricter eligibility. Check costs at Is Medicaid Free?.
“Big Beautiful Bill” Impact
OBBBA’s cuts may prompt states to restrict formularies or add $35 copays for specialists (October 2028), indirectly affecting prescription access. California’s Medi-Cal may face budget strains, potentially limiting specialty drug coverage.
Does Medicaid Cover Prescriptions for Children?
Yes, Medicaid covers prescriptions for children under 21 through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, a federal mandate. Coverage is comprehensive and free, including all medically necessary drugs.
Children’s Prescription Coverage
- Full Formulary: All FDA-approved drugs for pediatric use, including generics, brands, and specialty medications (e.g., for asthma, ADHD).
- No Limits: Unlimited prescriptions; no caps on quantity or refills if medically necessary.
- OTC Drugs: Covered if prescribed (e.g., allergy meds, vitamins).
- Vaccines: Free under Vaccines for Children (VFC) program.
In California, Medi-Cal covers all children’s prescriptions without copays. CHIP (for higher-income kids) follows similar rules.
“Big Beautiful Bill” Impact
EPSDT is protected, but reduced parental Medicaid enrollment (11.8 million adults) may affect family access to pharmacies or transportation for children’s prescriptions.
What Prescription Drugs Does Medicaid Cover?
Medicaid covers most FDA-approved drugs, but states can exclude or limit certain categories. Common coverage includes:
Covered Drugs
- Generics and Brands: Preferred generics have lower costs; brands require PA if generics available.
- Specialty Drugs: For chronic conditions (e.g., biologics for arthritis, antivirals for HIV). Covered but often with PA.
- Mental Health Medications: Antidepressants, antipsychotics (essential for adults/children).
- Pain Management: Opioids with limits (e.g., 7-day supply in Florida); non-opioids preferred.
- Contraceptives: Covered, including over-the-counter if prescribed.
Exclusions
- Cosmetic Drugs: E.g., for acne (unless severe), weight loss (e.g., Ozempic for non-diabetics excluded in some states).
- Experimental Drugs: Not covered unless in clinical trials.
- Over-the-Counter: Only if prescribed; varies by state (e.g., no coverage for vitamins in Texas).
States must cover all drugs from manufacturers in the Medicaid Drug Rebate Program. For dental coverage, see Does Medicaid Cover Dental?.
Costs of Prescriptions with Medicaid
Medicaid prescriptions are low-cost or free, with federal limits on copays:
- Children/Pregnant Women: Free (no copays).
- Adults: $1–$4 per prescription in some states (e.g., Florida, Kentucky). Exempt for preventive drugs.
- OBBBA Changes: $35 copays for specialists (October 2028) may not directly affect prescriptions, but funding cuts could increase generic requirements.
In California, Medi-Cal prescriptions cost $0–$5, with generics encouraged.
State-Specific Prescription Coverage
Coverage varies:
- California (Medi-Cal): Full coverage for adults/children; $1–$5 copays (waived for kids). PA for non-preferred drugs.
- Florida: $3 copays for adults; free for children. 3–6 prescription limit/month.
- New York: $1–$3 copays; unlimited for most.
- Texas: $3 copays for adults; free for children. Limited to generics for non-preferred.
- Non-Expansion States: Similar but stricter eligibility (e.g., Alabama covers prescriptions for disabled/parents only).
Use Medicaid.gov or state sites (e.g., www.dhcs.ca.gov) for PDLs. OBBBA cuts may prompt restrictions in budget-strained states.
How to Apply for Medicaid Prescription Coverage
- Check Eligibility: Use the Medicaid Eligibility Calculator or state portals to verify income (138% FPL for adults).
- Apply: Via Healthcare.gov, state sites (e.g., BenefitsCal.com for California), or county offices. See How to Apply for Medicaid.
- Get Prescriptions: Find in-network pharmacies (e.g., CVS, Walgreens accept Medicaid).
- Appeal Denials: If a drug is denied, request PA or appeal within 90 days.
Challenges and “Big Beautiful Bill” Impact
- Formulary Limits: PA delays can hinder access (e.g., 7–14 days for specialty drugs).
- Pharmacy Access: Rural areas have fewer Medicaid-accepting pharmacies.
- OBBBA Cuts: $1 trillion reduction may limit formularies or add copays ($35 for specialists by 2028), affecting 11.8 million enrollees. California may restrict specialty drugs due to budget strains.
Frequently Asked Questions (FAQs)
Does Medicaid cover prescriptions for adults?
Yes, in all states, but with formularies and possible PA for non-preferred drugs. Copays $1–$4 in some states.
Does Medicaid cover prescriptions for children?
Yes, fully covered under EPSDT, including all medically necessary drugs, with no copays.
What prescription drugs does Medicaid cover?
Generics, brands, specialty (with PA), mental health meds. Excludes cosmetic/weight loss drugs.
How much do prescriptions cost with Medicaid?
Free for children/pregnant women; $1–$4 copays for adults in some states. OBBBA may add $35 for specialists in 2028.
Does Medicaid cover brand-name drugs?
Yes, if generics unavailable or medically necessary, but PA often required.
Conclusion
Medicaid covers prescriptions comprehensively for children and variably for adults, with generics preferred and PA for brands. Costs are low ($1–$4 copays), but the “One Big Beautiful Bill” threatens access with $1 trillion cuts.
Check eligibility at Medicaid Eligibility Calculator or Income for Medicaid Eligibility. For application, see How to Apply for Medicaid. Dental details at Does Medicaid Cover Dental?. Contact your state Medicaid office (e.g., www.dhcs.ca.gov for California) for formularies and pharmacies.