The cost of prescription medications can become an expensive burden for many Medicare recipients. If they also qualify for Medicaid services, these costs may be alleviated under certain circumstances.
Prescription Drug Coverage Through Medicaid
Recipients who qualify for full Medicaid coverage may have their prescription costs entirely covered, as well. States can determine their own policies for optional Medicaid services, which includes prescription drug coverage. For states that do provide this benefit, there are additional rules that may impact what type of medications can be covered by Medicaid.
Commonly excluded types of drugs:
- Weight management medication, such as drugs meant to help with weight loss or gain.
- Reproductive medication to help with fertility issues.
- Medication for hair restoration or otherwise cosmetic-only treatment.
- Prescription-strength vitamins or minerals, with common exceptions being prenatal vitamins and certain fluoride preparations.
- Certain medications for cold symptom relief, such as cough suppressants or nasal decongestants.
- Over-the-counter medicines that do not require prescriptions.
Further restrictions may limit recipients to low-cost generic forms of certain medications. Recipients who require non-covered medications to treat a chronic illness may be able to appeal for special coverage through Medicaid. The process for this depends on which state and which private insurer is used to handle Medicaid benefits.
Some Medicaid insurers provide a separate monthly allowance for over-the-counter items such as vitamins or home health supplies. The amount, brands, and methods of ordering these items are determined by each provider.
Special Rules for Medicare-Medicaid Dual-Eligibles
Recipients who qualify for both Medicare and Medicaid services, known as dual-eligibles, may be subject to different rules when it comes to coverage for prescription drugs through Medicaid.
Enrollment in Medicaid, the Supplemental Security Income (SSI) program or any of the Medicare Savings Programs (MSP) means you qualify for an Extra Help, or Low-Income Subsidy (LIS) program that helps pay cost-sharing expenses related to Medicare’s Part D Prescription Drug Plan.
This includes the monthly Part D premium and copayments associated with your state’s formulary of prescription drugs. Participation can also eliminate a late enrollment penalty that the Part D program applies to recipients who purchase a plan after their initial enrollment period has ended.
Part D formularies may differ from Medicaid-specific formularies for your state, which means you may have more medication choices covered than if you received Medicaid prescription coverage alone.
Some dual-eligibles may receive prescription coverage through another program, such as an employer or union prescription drug plan. This can impact eligibility for Medicaid or for a Part D subsidy in some states, so check with your local office to verify your options. If you lose prescription drug coverage through another plan, you may qualify for a special enrollment period with Medicare’s Part D plan.