Georgia Medicaid Prescription Drug Coverage 2026: PDL & Copays

Georgia Medicaid prescription drug coverage is broad, and for most members the pharmacy copay is small. On the schedules Georgia's plans publish, a preferred drug costs $0.50 and a non-preferred drug carries a cost-based copay, while children, pregnant women, and several other groups pay $0. The schedules are not identical, so a member's copays depend on their plan.1 Who processes your prescription depends on how you are enrolled in Medicaid: fee-for-service members use OptumRx, while Georgia Families managed-care members use their plan's pharmacy benefit manager.2

In This Guide

• Who Administers Georgia Medicaid Prescription Drug Coverage?
• The Federal Framework: Rebates, PDLs, and Prior Authorization
• How a Prescription Gets Filled in Georgia
• The Preferred Drug List
• Prior Authorization in Detail
• Generic Substitution
• Member Copays in 2026
• Opioid Stewardship
• Dual-Eligibles: Medicare Part D, Not Medicaid Pharmacy
• Children Under 21: EPSDT Drug Coverage
• Worked Examples for Georgia
• Common Mistakes Georgia Members Make
• Get Help With Georgia Medicaid Prescription Drug Coverage
• Frequently Asked Questions
• Learn More

Who Administers Georgia Medicaid Prescription Drug Coverage?

Georgia Medicaid does not run every prescription through one statewide pharmacy benefit manager. Who administers your pharmacy benefit depends on how you are enrolled.2

Fee-for-service (FFS): OptumRx. Members in traditional fee-for-service Medicaid, which includes much of the Aged, Blind, and Disabled (ABD) population, have their outpatient pharmacy benefit administered by OptumRx. The Georgia Department of Community Health (DCH) names OptumRx as the Pharmacy Benefits Manager for the fee-for-service outpatient pharmacy program; it adjudicates claims at the point of sale and pays enrolled pharmacies weekly.2

Georgia Families CMO members: the CMO and its PBM. Members enrolled in a Georgia Families Care Management Organization (CMO) receive their pharmacy benefit through their CMO, which contracts with its own pharmacy benefit manager. These members do not use OptumRx for pharmacy. As of September 2026, Georgia Families has three current CMOs: Amerigroup Community Care, CareSource, and Peach State Health Plan. A 2024 reprocurement named a different slate for the next contract period (CareSource, Humana, Molina, and UnitedHealthcare), but that award sits in the protest phase, no notice of award has posted, and DCH is extending the three current contracts through June 30, 2027 while it waits. No member has been moved to a new plan and no go-live date is published, so keep using the pharmacy contact on your member ID card.5

Gainwell Technologies: the fiscal agent. Gainwell has been DCH's fiscal agent since 2010, running the GAMMIS claims-and-eligibility system and staffing its customer-service lines. It is not the pharmacy benefits manager; DCH names OptumRx in that role for fee-for-service.2

Know which track you are on, and do not assume the two use the same drug list. Georgia's Office of Health Strategy and Coordination reported four entities providing coverage, the three CMOs plus fee-for-service, "resulting in four different drug lists."2 That came from a January 2023 study, so confirm the current arrangement with DCH.

The Federal Framework: Rebates, PDLs, and Prior Authorization

Prescription drugs are an optional Medicaid benefit under federal law, but every state, including Georgia, covers them. Three federal rules shape how Georgia's pharmacy benefit works.

The Medicaid Drug Rebate Program. Under Social Security Act Section 1927 and 42 CFR 447.509, a manufacturer must sign a rebate agreement with the Centers for Medicare and Medicaid Services (CMS) and pay states a rebate on every Medicaid prescription before its products are covered. For a brand drug the basic rebate is the greater of 23.1 percent of the Average Manufacturer Price (AMP) or the gap between AMP and best price; for a generic it is 13 percent of AMP. An inflation rebate is added when a drug's AMP outruns the Consumer Price Index, and since the American Rescue Plan Act sunset the old 100-percent-of-AMP ceiling for rebate periods from January 1, 2024, that rebate can now exceed the drug's own AMP.6

PDL and prior authorization authority, with member safeguards. Federal law (Social Security Act Section 1927(d); 42 USC 1396r-8(d)) lets a state subject any covered outpatient drug to prior authorization and establish a formulary, which is the basis for a preferred drug list on which non-preferred drugs require PA. That authority is bounded: the PA system must respond within 24 hours of a request, and the pharmacy may dispense at least a 72-hour emergency supply while PA is pending.3

Drug utilization review. Every state Medicaid program must run a drug use review (DUR) program under Social Security Act Section 1927(g), combining prospective review (a point-of-sale check before each prescription is filled) with retrospective review (periodic examination of claims data to spot overuse or inappropriate prescribing). Nursing facility residents are carved out of the second half: a state need not run additional drug use reviews on drugs dispensed to residents of facilities already following the federal drug-regimen-review rules. The SUPPORT for Patients and Communities Act of 2018 added the opioid duties separately, at Social Security Act Section 1902(a)(85) and (oo) rather than inside 1927(g); since October 1, 2019 states must run safety edits on subsequent opioid fills and on maximum daily morphine milligram equivalents.7

How a Prescription Gets Filled in Georgia

The Preferred Drug List

For a fee-for-service member, the DCH PDL decides which drugs fill easily and which need extra steps. CMO members go by their own plan's list, so check the one that applies to your track before assuming a drug is preferred.2 The DCH list is maintained by the department's Pharmacy and Therapeutics Committee, which meets quarterly and weighs clinical evidence, supplemental rebates, net cost, and patient access, keeping at least one preferred agent in each major class.

Drugs on the PDL are dispensed without prior authorization; non-preferred drugs require PA. Low-cost generics such as lisinopril, omeprazole, sertraline, and risperidone are usually preferred, while brand-only equivalents usually are not. Classes where clinical practice demands choice, anticonvulsants and antiretrovirals among them, are typically kept open-access. The PDL is published quarterly on the DCH pharmacy program portal. If a drug was just rejected at the counter, our Georgia Medicaid Preferred Drug List guide walks through why, and how to get a non-preferred drug approved.

Prior Authorization in Detail

Several PA pathways exist: non-preferred drug PA, step therapy, specialty drug PA, quantity or duration limits, and dispense-as-written (DAW) PA. Each turns on the prescriber documenting why the preferred or generic alternative is inadequate.

Federal law sets the timing floor: a standard PA decision must be made within 24 hours of receiving complete information, and the pharmacy may dispense at least a 72-hour emergency supply if PA is pending and the prescriber is unavailable.3 If PA is denied, the prescriber can resubmit with more detail or file an internal appeal with the plan that administers the benefit (OptumRx/DCH for FFS, the CMO otherwise). Beyond that, federal law gives a Medicaid applicant or beneficiary the right to a fair hearing before the state agency, and the regulation names a prior-authorization decision among the things that right reaches. It is not unconditional: no hearing is required where the sole issue is a federal or state law forcing an automatic change across some or all beneficiaries.8 A managed-care member normally waits for the plan's notice upholding its decision, though a plan that misses the notice and timing rules is deemed to have exhausted its own appeal. The state must then allow 90 to 120 calendar days from that notice to request a hearing. Do not use the whole window. Coverage does not continue on its own: it stops unless the member requests both the hearing and continued benefits within 10 calendar days of the notice. Take the full 90 days and you keep the appeal but lose the drug in the meantime.9 In Georgia, state agencies transmit the hearing requests of Medicaid applicants and beneficiaries, including requests prompted by a denial of application or a reduction or termination of benefits, to the Georgia Office of State Administrative Hearings (OSAH).10 The step-by-step approval playbook lives in the PDL guide.

Generic Substitution

Federal Medicaid law and DCH policy require pharmacists to substitute an FDA-rated bioequivalent generic whenever one exists. If none exists, the pharmacy dispenses the brand; if the prescriber writes "dispense as written" or "brand medically necessary," the brand goes out only if PA approves the DAW request.3 That takes a documented clinical reason, such as an adverse reaction to the generic or a narrow-therapeutic-index drug, and most DAW requests are denied because generics are clinically interchangeable for most drugs.

Member Copays in 2026

There is no single figure that covers every member: each Georgia Families Care Management Organization publishes its own schedule, and they are not identical. CareSource, for example, publishes $0.50 for a preferred drug and a cost-based copay for a non-preferred one. Cost-based copays scale with what the care costs: $0.50 at $10.00 or less, $1 from $10.01 to $25.00, $2 from $25.01 to $50.00, and $3 at $50.01 or more.1 Several groups pay nothing for covered care, among them Medicaid members under 21, pregnant women, nursing facility residents, children in foster care, hospice members, members in the Breast and Cervical Cancer program, and American Indians or Alaska Natives. That exemption is bounded by program: PeachCare for Kids members age six and over pay the $0.50 preferred-drug copay. Whether a six-year-old is exempt is not settled between the plans' own pages, so confirm it with yours.1

These copays sit under the federal maximum, but that maximum is not the $4-and-$8 pair printed in 42 CFR 447.53(b). Those are base figures for families at or below 150 percent of the poverty level, and they have been indexed upward by the medical-care CPI every October since 2015, so the amount actually allowed today is higher. Being in an exempt group is no guarantee of free drugs either, because the agency may still charge an exempt member up to that maximum for a non-preferred drug. There is a way out of that charge: where your prescriber determines the preferred drug will be less effective for you or will cause adverse effects, the state must have a timely process that limits your cost sharing to the preferred-drug amount. And for categorically needy and cost-sharing-exempt low-income members a provider generally may not deny a covered service because the member cannot pay (42 CFR 447.52(e)(2)).11 The full at-the-counter breakdown is in the PDL guide's what-you-pay section; the schedule across all services is in our Georgia Medicaid copays guide.

Opioid Stewardship

Georgia runs point-of-sale safety edits and claims review aimed at opioid over-utilization, and higher-risk claims (high daily doses, early refills, opioid-benzodiazepine combinations) can trigger prior authorization or pharmacist review before dispensing.7 Day-supply and morphine-milligram-equivalent thresholds sit in DCH and OptumRx policy; confirm the current limits with the DCH pharmacy program.

Two related coverage points matter for members. Naloxone, the opioid-overdose reversal medication, is broadly accessible: the FDA approved Narcan nasal spray for over-the-counter use on March 29, 2023, and the CDC says naloxone is available over the counter in all 50 states with no prescription needed. That reaches the nasal spray only. Other formulations and doses, the injectable among them, stay prescription-only, and how a state Medicaid program covers naloxone varies, so confirm coverage and any copay with your own plan.12 Medication for opioid use disorder is covered too: buprenorphine can be prescribed in office-based treatment, while methadone for opioid use disorder may generally be dispensed only through an Opioid Treatment Program certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and registered with the Drug Enforcement Administration, not a regular pharmacy. One carve-out matters for older adults: OTP certification is not required to start or continue methadone for a patient admitted to a hospital or long-term care facility that is DEA-registered as a hospital or clinic, where the patient was admitted for something other than opioid use disorder and needs methadone during the stay.13

Dual-Eligibles: Medicare Part D, Not Medicaid Pharmacy

For dual-eligibles (members with both Medicare and Medicaid), prescription drugs are covered under Medicare Part D, not Medicaid pharmacy. See the Georgia dual-eligibles guide for how the two programs fit together.

Full duals have incomes under the Low-Income Subsidy (LIS, or Extra Help) limit and qualify for the full subsidy, and Part D now carries an annual out-of-pocket cap ($2,100 in 2026) and a $35 monthly cap on covered insulin.4,14,15 A few drugs Part D excludes (certain over-the-counter and family-planning products) may be covered by Medicaid as wraparound; the PDL guide covers which card to use.

Children Under 21: EPSDT Drug Coverage

Under Medicaid's Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, children and youth under age 21 are entitled to prescription drugs medically necessary to correct or ameliorate a condition discovered by an EPSDT screening, even when those drugs fall outside the limits Georgia places on the adult drug benefit. Both halves travel together: necessary treatment, for a condition the screening found.16 In practice, that means a child who needs a non-preferred medication, a compounded formulation, or an evidence-based off-label use can be covered with medical-necessity documentation, and the pharmacy copay for a child under 21 is $0.1

Worked Examples for Georgia

Example 1: A Dual-Eligible Senior (Mrs. Anderson, 67)

Mrs. Anderson has hypertension and type 2 diabetes and is enrolled in both Medicare and Georgia Medicaid, so her drugs come under Medicare Part D. As a full dual she qualifies for the full Extra Help subsidy: her lisinopril, metformin, and atorvastatin each cost no more than $5.10, and her insulin no more than $5.10 generic or $12.65 brand.4 That is well under the $35 monthly insulin cap every Part D enrollee gets.15 She uses her Part D card at the pharmacy, not her Medicaid card.

Example 2: A Fee-for-Service Member After Surgery (Mrs. Park, 62)

Mrs. Park is an ABD fee-for-service member recovering from outpatient surgery. Her surgeon prescribes a short course of an opioid pain reliever. Because she is in FFS, her claim is processed by OptumRx, and an opioid safety edit may apply at the point of sale.2,7 She pays a nominal preferred-drug copay, $0.50 on the Georgia schedules that publish one.1 If she needs more days of medication, her surgeon must reassess and write a new prescription, because Schedule II opioids are not auto-refilled.

Common Mistakes Georgia Members Make

• Filling at an out-of-network pharmacy. A pharmacy must be enrolled in Georgia Medicaid and in your benefit's network (OptumRx's for FFS, or your CMO's) to bill it.2
• Insisting on brand when a generic is available. DAW prior authorization is rarely approved; accept the generic unless your prescriber documents a specific clinical reason.
• Not requesting the 72-hour emergency supply when PA is pending. Federal law requires it, and pharmacies sometimes need a reminder.3
• Calling the wrong place for a pharmacy problem. CMO members call the member-services number on their ID card; on the OptumRx-administered FFS benefit, the pharmacy's rejection code and the prescriber's PA submission are where the problem gets solved.2
• Assuming all dual-eligibles use Medicaid pharmacy. Full duals use Medicare Part D, not Medicaid pharmacy.

Get Help With Georgia Medicaid Prescription Drug Coverage

For a denial, a PA question, or trouble finding a covered drug, start below. For dual-eligibles, GeorgiaCares is the State Health Insurance Assistance Program for Part D questions.

Learn More

Find personalized help navigating Georgia Medicaid pharmacy coverage at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.