Pharmacy

Handbook Content

Terms and Meanings

Some terms that we use in this chapter may not be familiar. These terms and their meanings are listed below

  • Anticoagulants: Medication that keeps your blood from becoming too thick.
  • Approved/Authorized: The decision Medicaid makes to pay for a service.
  • Contraceptives: Medications or devices that keep someone from becoming pregnant.
  • Durable Medical Equipment: Items or supplies you need to use regularly because of an injury or illness.
  • Hospice: Special services for a person who is in the final stages of their life and after their death.
  • Immunizations: The act of building a resistance to diseases.
  • Liability: When you are responsible for payment or another action.
  • Limits: The most Medicaid will cover for costs or services.
  • Prescriptions: An order from your provider for medications, equipment, testing, or supplies.
  • Provider: A doctor, nurse, therapist, or another qualified health care professional.
  • Recipient Liability/Client Share: The amount of money you must pay to help cover the costs of your health care.

  • Services: Care, treatments, testing, checkups, equipment, supplies, and other ways your health care providers help you stay healthy. 

Covered Prescriptions

Medicaid covers most prescribed medications. Some over the counter (OTC) medications and nutritional supplements may also be covered. Your provider needs to write an order for medications or nutritional supplements if Medicaid is to cover the costs. 

Medicaid also covers some medical supplies. Your provider needs to write a prescription for these supplies to be covered by Medicaid:

  • Inhaler spacers
  • Blood sugar test strips
  • Continuous glucose monitors
  • Needles and syringes for insulin or other medications that are injected

There are many types of prescriptions that your provider may order for you such as:

  • Antibiotics
  • Anticoagulants
  • Antipsychotics
  • Cancer treatment medications
  • Diuretics
  • Hormones
  • Immunizations
  • Inhaler spacers and other durable medical equipment
  • Insulin, diabetic testing, and insulin delivery supplies
  • Nasal medications (sprays in your nose)
  • Ophthalmic medications (drops in your eye)
  • Otic medications (drops in your ear)
  • Pain relievers
  • Topical medications (creams on your skin)
  • Vasodilators

Covered prescriptions are not limited to the list above.

You can talk to your provider or pharmacy to make sure Medicaid covers your prescription. 

Prescription Coverage Limits

Covered medications and supplies may have limited Medicaid coverage. This means that Medicaid may cover costs based on how often your prescription is filled or how much medication is ordered. Medicaid may need more information from your provider or pharmacy to be able to cover some medications.  Your provider or pharmacy will help with these processes. 

Some examples of limited medications and supplies include:

  • OTC medications (Aspirin, acetaminophen, NSAIDS, antacids, etc.)
  • Nicotine replacement products
  • Emergency and maintenance contraceptives
  • Lice treatments
  • Dietary supplements
  • Weight control medications 
  • Compounds

There are a small number of medications that are paid by Medicaid for someone who has Medicaid AND Medicare. An example would be some cough and cold medications. Otherwise, you will need to pay for any Medicare Part D copays for your medications. 

Non-Covered Prescriptions

Medicaid does not cover the following:

  • Shipping and delivery costs
  • Medications made by manufacturers that do not participate with Medicaid
  • Experimental medications
  • Expired medications
  • Medications used for cosmetic reasons (such as hair growth, hair removal, etc.)
  • Fertility medications
  • Erectile dysfunction medications
  • Medications that are not being used for a medically accepted use

If you live in a nursing home, some medications and supplies are covered as part of your nursing home stay. Medicaid will not cover additional:

  • OTC medications (Aspirin, acetaminophen, NSAIDS, antacids, etc.)
  • Durable medical equipment
  • Vitamins

Using Out-of-State Pharmacies

Medicaid covers pharmacy costs for participating pharmacies in North Dakota, Montana, South Dakota, and Minnesota. Your pharmacy may need to get approval from Medicaid before you can fill a prescription at a pharmacy outside of these states. Prescriptions from outside of the United States (e.g. Canada or Mexico) are not covered by Medicaid.

COST

Medicaid does not have copays, but you may have to pay for part of your prescription if your Medicaid coverage has Recipient Liability. Recipient Liability, or client share is an amount you need to pay toward your medical costs each month before Medicaid will pay for medical services. This includes the cost of your prescriptions.  

Your pharmacist can teach you about your prescription and how to use your supplies or take medications.  

If you have questions about your coverage for prescriptions, you can ask: 

  • Your provider 
  • Your pharmacist 
  • Our Provider Relations department

Contact Information Mentioned in this Chapter:

  • Provider Relations
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