State Medicaid Formularies: What Drugs Are Covered and Why It Matters
When you're on state Medicaid formularies, a list of prescription drugs approved for coverage under each state's Medicaid program. Also known as Medicaid drug lists, these formularies determine exactly which medications you can get at a low or no cost — and which ones you might have to pay for yourself or fight to get approved. Every state runs its own Medicaid program, so the drugs covered in Texas aren't the same as those in New York or California. These lists aren't random. They're built by pharmacy and therapeutics committees using clinical evidence, cost data, and input from doctors who treat Medicaid patients.
What’s on the list? Usually, generic versions of common drugs come first — like metformin for diabetes or lisinopril for high blood pressure — because they’re cheaper and just as effective. Brand-name drugs are often excluded unless there’s no generic option, or a patient has a medical reason they can’t take the generic. That’s where drug tiering, a system that groups medications by cost and coverage rules. Also known as formulary tiers, it determines how much you pay out of pocket comes in. Tier 1 might be $5 for generics. Tier 3 or 4? Could be $50 or more for a brand-name drug. And some drugs are outright blocked unless your doctor files a prior authorization request — a form that explains why you need it.
These formularies also change. States update them every few months based on new generics, safety alerts, or budget cuts. A drug you got last year might disappear from the list this year. That’s why it’s so important to check your state’s current formulary before filling a script. You can find them on your state’s Medicaid website — they’re public documents. If your medication gets removed, you might qualify for an exception. Many people don’t know this: you can appeal. Your doctor can submit paperwork showing the drug is medically necessary. In fact, studies show over half of these appeals get approved when supported by clinical evidence.
And it’s not just about cost. Some states restrict high-risk drugs like opioids, benzodiazepines, or certain antipsychotics unless specific criteria are met. This is partly to prevent misuse, but it also means people with chronic conditions sometimes face delays. Meanwhile, newer drugs — like GLP-1 agonists for weight and diabetes — are often excluded entirely because of their price. That’s why so many Medicaid patients end up on older, cheaper alternatives that still work, even if they’re not the flashiest option.
What you’ll find in the posts below are real stories and practical guides about how these formularies impact daily life. You’ll see how people navigate prior authorizations, why switching to a generic can backfire due to the nocebo effect, and how pharmacists help patients fight for coverage. There are deep dives into how Medicare Part D changes affect Medicaid dual eligibles, how geriatric patients get caught in polypharmacy traps because of formulary restrictions, and what to do when your heart medication or antidepressant suddenly disappears from the list. These aren’t abstract rules — they’re life-changing decisions made in a system that’s often confusing and inconsistent.
