Medicaid Prescription Copay

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The New York State Medicaid Pharmacy program covers medically necessary FDA approved prescription and non-prescription drugs for Medicaid fee-for-service enrollees. Enrollees in mainstream Medicaid Managed Care and Family Health Plus plans receive pharmacy benefits directly through the managed care plans. Prescription drugs require a prescription order with appropriate required information. Non-prescription drugs, often referred to as Over-the-Counter or OTC drugs, require a fiscal order (a fiscal order contains all the same information contained on a prescription). Certain drugs/drug categories require the prescribers to obtain prior authorization.

Pharmacy program and billing policy and other pharmacy related information can be found in the NYS MMIS Pharmacy Provider Manual and the Department's Medicaid Update. You may also contact us at [email protected] or (518) 486-3209 for Medicaid pharmacy policy related questions.

For more information and copies of letters sent to pharmacists and prescribers, please see Pharmacy Provider Communications below.

Medicare Part B, Medicare Part D, supplemental insurance, Medicare Advantage Plan premiums, Medicaid spend-downs or copays You must Have a household income at or below 500% of the Federal Poverty Level Be a U.S. Citizen or permanent resident of the U.S. Or Puerto Rico Have medical insurance and/or prescription insurance. Patient Advocate Foundation's Co-Pay Relief program exists to help reduce the financial distress patients, and their families face when paying for treatment. We believe that no patient should go without life changing medications because they cannot afford them. We are here to help. In most cases, you'll pay a small amount for your covered drugs. If you have full coverage from Medicaid and live in a nursing home, you pay nothing for covered prescription drugs. If you have full coverage from Medicaid and live in an assisted living or adult living facility, or a residential home, you'll pay a small Copayment for each drug. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) and subsequent regulations require coordination between CMS, State programs, insurers, employers, and all other payers of prescription drug benefits to ensure that the prescription drug benefits provided to Medicare beneficiaries enrolled in Medicare Part D are maximized and the integrity of the Medicare program. If you qualify for Mississippi Medicaid health benefits, some medical services may require a copay (small fee). Copays are not required from these groups of people: children under the age of 18. Prescription drugs: per prescription for generic drugs: $3: Prescription drugs.

The following information may be of interest to pharmacists and prescribers:

Pharmacy Program Information

  • Emergency Services Only Pharmacy Coverage (Web) - (PDF) - 6.9.20
  • Information on Medicaid Pharmacy MRTs (Web)
  • Pharmacists as Immunizers
    • NYS Medicaid Program Pharmacists As Immunizers Fact Sheet (Web) - (PDF) - September 2020
  • Medicaid Program - Dispense Brand Drugs When Less Expensive (Web)
    • Dispense Brand Name Drugs When Less Expensive Initiative (PDF)
  • Medicaid Pharmacy Reimbursement Methodology (PDF)
    • Archived Information Regarding Average Acquisition Cost (AAC)/Cost of Dispensing (COD)Cost of Dispensing (Web)
  • Medicaid List of Reimbursable Drugs (Formulary File) (Web)
  • Medicaid Mandatory Generic Drug Program (Web)
  • The New York State Medicaid Mandatory Generic Clinical Exemption Request Form (PDF)
  • Medicaid Pharmacy Preferred Drug Program (Web)
    • Medicaid Preferred Drug Program Annual Reports to the Governor and Legislature (Web)
  • Medicaid Preferred Diabetic Supply Program (Web)
  • Medicaid Clinical Drug Review Program (Web)
  • Medicaid Pharmacy and Therapeutics Committee (Web)
  • Medicaid Drug Utilization Review Program (DUR) (Web)
    • Opioid Management (Web)
    • Electronic Mailing Lists (Web)
  • Medicaid Medication Therapy Management Pilot Program (Web)
  • Medicaid Prescriber Education Program (Web)
  • Medicaid and the Medicare Part D Prescription Drug Benefit (Web)
    • Drugs covered by Medicaid for Dual Eligible Members (Web)
  • Medicaid Child (Foster) Care Drug Carve-out List (Web)
  • Medicaid Drug Rebate Program
    • Generic Drug CPI Initiative
      • Stakeholder Communication Letter (Web) - (PDF) - December 2016
      • Drug list (Web) - (PDF)

Related Programs and Information

  • Practitioner Adminstered Drug Policies and Billing Guidance (Web)
  • Pharmacy Provider Communications (Web)
  • Medicaid Update - A monthly publication of the New York State Department of Health, Office of Medicaid Management (Web)
  • FDA Press Announcements (Web)
  • FDA Medical Product Safety Information (Web)

Prescription drug coverage is one of the optional benefits that individual states may choose to provide to their Medicaid recipients. Currently, all the states offer outpatient prescription drug coverage. So the simple answer is yes, Medicaid does cover the costs of prescription drugs. However, this doesn’t mean all prescriptions are completely covered.

Each state can choose which medications they are willing to cover and which prescriptions they will not cover. They can also set rules regarding prescription co-payments or shared costs. However, there are limits placed on how much the state can make the patient pay for prescriptions covered by healthcare benefits.

First, the individual states can decide which prescriptions to include on their preferred list and which ones to include on their non-preferred list. Generally speaking, if there is a generic version of an otherwise very expensive medication, the generic version will be on the preferred list while the more expensive one will be on the non-preferred list.

Once a state has their list of preferred and non-preferred drugs, they are allowed to charge a co-payment of up to 20% of the non-preferred prescription cost for recipients with an income higher than 150% FPL. Even paying only 20% can get very expensive, so many request the generic versions in order to ensure little to no out-of-pocket expenses.

Virginia Medicaid Prescription Copay

Medicaid Prescription Copay

Some states, such as California, simply provide an approved list of prescriptions. Instead of charging varying co-payments to discourage the use of more expensive drugs, they simply won’t cover them. In that situation, a patient with a prescription for a drug not on the approved list will have to either pay for the drug out-of-pocket, ask their doctor for a generic alternative, or have the pharmacist submit a special request on their behalf.

If there is a clear medical reason why you need a specific drug that is not on the approved list, and that drug is essential to you staying healthy or recovering from an illness, you may be granted special approval. While that particular drug still won’t be added to the approved list for everyone, it will be covered for you while you need it.

Older patients that are eligible for both Medicaid and Medicare may apply for a Medicare Part D plan to cover the cost of their prescriptions. Some states require that patients who are eligible for Medicare to apply for Part D coverage regardless of what other coverage they have.

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