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 copay schedules Georgia's plans publish, a preferred drug costs $0.50 and a non-preferred drug carries a cost-based copay, and children, pregnant women, and several other groups pay $0. Those published 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. Per the Georgia Department of Community Health (DCH), OptumRx is the Pharmacy Benefits Manager for the Georgia Medicaid Fee For Service Outpatient Pharmacy Program. OptumRx processes FFS outpatient pharmacy claims at the point of sale and pays enrolled pharmacies on a weekly cycle.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 2026, Georgia Families has three current CMOs: Amerigroup Community Care, CareSource, and Peach State Health Plan.5 Rosters can change, so confirm your plan's pharmacy contact on your member ID card.

Gainwell Technologies: the fiscal agent. Gainwell Technologies has served since 2010 as DCH's fiscal agent for Medicaid and PeachCare for Kids, running the GAMMIS claims-and-eligibility system and staffing its customer-service lines. DCH names OptumRx, not Gainwell, as the pharmacy benefits manager for the fee-for-service program.2

The practical takeaway is to know which track you are on, and not to assume the two apply 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," with CMOs or their subcontracted PBMs generally preferring to manage their own.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 the Medicaid Drug Rebate Program (Social Security Act Section 1927; 42 CFR 447.509), a drug manufacturer must sign a rebate agreement with the Centers for Medicare and Medicaid Services (CMS) and pay states a rebate for every Medicaid prescription dispensed before its products are covered. For a brand (single source or innovator) drug, the basic rebate is the greater of the difference between the Average Manufacturer Price (AMP) and the best price, or 23.1 percent of AMP. For a generic (noninnovator) drug, the basic rebate is 13 percent of AMP. An additional inflation-based rebate applies when a drug's AMP rises faster than the Consumer Price Index. That inflation rebate used to be held down by a ceiling that capped a drug's total rebate at 100 percent of AMP, but the American Rescue Plan Act of 2021 sunset that ceiling for rebate periods beginning on or after January 1, 2024, so on a drug whose price has long outrun inflation the 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). It combines prospective review (a point-of-sale check before each prescription is filled) and retrospective review (periodic examination of claims data to spot overuse or inappropriate prescribing). The SUPPORT for Patients and Communities Act of 2018 strengthened these requirements for opioids, directing states to adopt safety edits aimed at opioid over-utilization within the DUR framework.7

How a Prescription Gets Filled in Georgia

The member does not see the financial flow. They pay the copay and walk out with the drug.

The Preferred Drug List

For a fee-for-service member, the DCH PDL is the single biggest determinant of which drugs are easy to fill and which require extra steps. CMO members are governed by their own plan's drug list instead, so check the list that applies to your track before assuming a drug is preferred.2 The DCH list is maintained by the department's Pharmacy and Therapeutics (P&T) Committee, which meets quarterly to review therapeutic classes. The committee weighs clinical evidence, supplemental rebate offers from manufacturers, total net cost, and patient access, and it ensures at least one preferred agent in each major class.

Drugs on the PDL are dispensed without prior authorization. Non-preferred drugs require PA. Typical decisions follow a familiar pattern: low-cost generics such as lisinopril, omeprazole, sertraline, and risperidone are usually preferred, while brand-only equivalents are usually non-preferred or require PA. Some classes where clinical practice demands choice (for example anticonvulsants and antiretrovirals) are kept open-access and are typically available without PA. The PDL is published quarterly on the DCH Georgia Medicaid pharmacy program portal. If a drug you need was just rejected at the counter, our Georgia Medicaid Preferred Drug List guide walks through why that happens and exactly 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 when a brand is requested over an available generic. Each turns on the prescriber documenting why the preferred or generic alternative is inadequate for the patient.

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 clinical detail or file an internal appeal with the plan that administers the benefit (OptumRx/DCH for FFS, the CMO for managed-care members). Beyond that, federal law guarantees every Medicaid beneficiary the right to a fair hearing before the state agency when a claim for covered benefits or services is denied.8 A managed-care member must exhaust the plan's one internal appeal first, and the state must then allow no less than 90 and no more than 120 calendar days from the plan's notice of resolution to request that hearing.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, including what documentation moves a PA request and how to invoke the emergency supply, lives in the PDL guide.

Generic Substitution

Federal Medicaid law and DCH policy require pharmacists to substitute an FDA-rated bioequivalent generic for a brand prescription whenever one exists. The exceptions are narrow: if no generic exists, the pharmacy dispenses the brand; if the prescriber writes "dispense as written" or "brand medically necessary," the pharmacist may dispense the brand only if PA approves the DAW request.3 DAW approval requires a documented clinical reason, such as an adverse reaction to the generic or a narrow-therapeutic-index drug. In practice, most DAW requests are denied because generic equivalents are clinically interchangeable for most drugs.

Member Copays in 2026

Georgia Medicaid pharmacy copays are nominal, but there is no single figure that covers every member. Each Georgia Families Care Management Organization publishes the copay schedule its own members pay, and the published schedules are not identical, so a member's copays depend on their plan. CareSource, for example, publishes $0.50 for a preferred drug and a cost-based copay for a non-preferred drug. Cost-based copays scale with what the care costs: $0.50 when it costs $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 no copay at all for covered care, including 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 are not exempt and do pay the $0.50 preferred-drug copay.1

These copays sit well under the federal ceiling of $4 for a preferred drug and $8 for a non-preferred drug, 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 the copay (42 CFR 447.52(e)(2)).11 The full at-the-counter breakdown, including the exemption table and what happens if you cannot pay, is in the PDL guide's what-you-pay section; the broader cost-sharing schedule across all services is in our Georgia Medicaid copays guide.

Opioid Stewardship

Georgia implements opioid utilization controls through the DUR framework that the SUPPORT for Patients and Communities Act of 2018 strengthened. The state runs point-of-sale safety edits and claims review aimed at opioid over-utilization, and higher-risk opioid claims (high daily doses, early refills, opioid-benzodiazepine combinations) can trigger prior authorization or pharmacist review before dispensing.7 Specific day-supply and morphine-milligram-equivalent thresholds are set in DCH and OptumRx pharmacy policy; confirm the current limits with the DCH pharmacy program before prescribing.

Two related coverage points matter for members. Naloxone, the opioid-overdose reversal medication, is broadly accessible: the FDA approved over-the-counter Narcan nasal spray in March 2023, so naloxone is now available without a prescription in all 50 states, and Medicaid programs cover it through the pharmacy benefit.12 Medication for opioid use disorder is also covered: buprenorphine can be prescribed in office-based treatment, while methadone for opioid use disorder may 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.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 dual-eligibles have incomes under the Low-Income Subsidy (LIS, or Extra Help) limit and qualify for the full subsidy, which sharply reduces Part D drug costs, 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 does not cover (certain over-the-counter products and family-planning drugs) may be covered by Medicaid as wraparound; the PDL guide covers which card to use at the pharmacy and how the wrap-around works.

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 medically necessary prescription drugs even when those drugs fall outside the limits Georgia places on the adult drug benefit.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. Her drugs are covered under Medicare Part D, not Medicaid pharmacy. Because she is a full dual, she qualifies for the full Extra Help subsidy, so her lisinopril, metformin, and atorvastatin each cost no more than the $5.10 generic copay, and her insulin costs no more than her Extra Help copay of $5.10 for a generic or $12.65 for a brand.4 That is well under the $35 monthly insulin cap that applies to every Part D enrollee.15 She uses her Part D plan card at the pharmacy, not her Medicaid card.

Example 2: A Pregnant Member (Mrs. Smith, 28)

Mrs. Smith is pregnant and on Georgia Medicaid. Her prenatal vitamin, anti-nausea medication, and iron supplement are all filled at her community pharmacy with no prior authorization and a $0 copay, because pregnant women are exempt from cost sharing.1

Example 3: A Child With ADHD (Tommy, 8)

Tommy is enrolled in Amerigroup (Georgia Families) and was recently diagnosed with ADHD. His generic methylphenidate ER is preferred, requires no PA, and costs $0 under EPSDT.1 If his pediatrician wants brand Concerta dispensed as written, PA is required and is likely denied, because the generic is therapeutically equivalent; EPSDT does not override the generic-substitution rule.16

Example 4: 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 participate in your benefit's network (the OptumRx FFS network, or your CMO's network) to bill your pharmacy benefit.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 should call the member-services number on their ID card; FFS members are on the OptumRx-administered benefit, so the rejection code from the pharmacy and the prescriber's PA submission are where an FFS pharmacy 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

If you have a prescription denial, a PA question, or trouble finding a covered drug, the resources below can help. For dual-eligibles, GeorgiaCares is the State Health Insurance Assistance Program for Medicare 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.