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  Pharmacy Services 

The basic objective of the Medicaid Pharmacy Services program is to provide needed pharmaceuticals for the purpose of saving lives in emergency situations or during short term illness, to sustain life in chronic or long term illness, or to limit the need for hospitalization.

Covered Service Limitations: Covered pharmacy services include the provision of most legend (i.e., those products requiring a prescription in order to be dispensed) as well as non-legend (i.e., over-the-counter) rebated generic pharmaceuticals. For each pharmaceutical dispensed, a valid prescription authorized by a licensed practitioner (physician, dentist, optometrist, podiatrist, or other health care provider authorized by law to diagnose and prescribe drugs and devices) must be on file. Medicaid-eligible beneficiaries from birth to the date of their 21st birthday are allowed unlimited prescriptions or refills per month. For beneficiaries over the age of 21, unless otherwise specifically allowed, the Medicaid Pharmacy Services program sponsors reimbursement for a maximum of four covered prescriptions or refills per month. However, certain products and product categories are exempt from the monthly prescription limitation. Additionally, for adult beneficiaries needing more than four prescriptions within a given month, a prescription limit override process is available to the pharmacist for those essential prescriptions that meet the specified override criteria.

Non-controlled substance prescriptions: 1) limited to a maximum 34 days' supply per prescription/refill and 2) at least 75% of the current prescription must be used (as directed on the prescription) before Medicaid pays for a refill of the prescription. Controlled substance prescriptions: 1) state and federal regulations determine the allowed dispensed quantities and 2) state and federal regulations determine the allowed timeline for dispensing any authorized refills.

Certain products require prior authorization, meaning that coverage is determined through Pharmacy Services’ clinical prior authorization process. Approval for Medicaid coverage of products requiring prior authorization is patient-specific and is determined according to certain established criteria. Medicaid pays for most rebated generic pharmaceuticals; however, most brand name products for which generics are available require prior authorization in order to be considered for reimbursement.



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