Georgia Medicaid Prescription Drugs and PDL (2026): Pharmacy Benefit, PA, Copays

Georgia Medicaid prescription drug coverage operates under the federal Medicaid Drug Rebate Program framework administered by CMS, with a unified statewide Preferred Drug List (PDL) administered by the Georgia Department of Community Health (DCH) and the Georgia Drug Utilization Review Board. Under the unified PDL, all four Georgia Families Care Management Organizations (Amerigroup, Peach State, CareSource, WellCare) pay for member prescriptions but follow the same PDL and prior authorization criteria. This guide walks through the federal framework, the Georgia PDL structure, prior authorization mechanics, copays, the 90-day mail-order option, specialty pharmacy, and how Medicare Part D interacts with Medicaid for dual-eligibles.

By Brevy Care Team · Last verified May 12, 2026

The federal Medicaid Drug Rebate Program framework for Georgia Medicaid prescription drug coverage

The federal Medicaid Drug Rebate Program (MDRP), codified in the Social Security Act and federal Medicaid regulations, structures every state's outpatient pharmacy benefit. Drug manufacturers that want their drugs eligible for Medicaid coverage must enter a federal rebate agreement with CMS and pay rebates to state Medicaid programs for every unit dispensed. In exchange, state Medicaid programs must cover essentially all of the manufacturer's FDA-approved outpatient drugs, with a narrow list of excludable categories.

The practical consequence: essentially every FDA-approved drug from a manufacturer with a rebate agreement is potentially covered. States can use utilization-management tools (prior authorization, step therapy, quantity limits) to steer prescribing, but cannot categorically exclude a manufacturer's drugs from coverage. This is meaningfully different from commercial insurance, which routinely excludes drugs and classes.

The Affordable Care Act extended the rebate program to drugs dispensed through Medicaid managed care organizations, closing a gap that had previously excused MCO drug spending from rebate collection. The Inflation Reduction Act added Medicare drug-price negotiation and other reforms that interact with Medicaid rebate calculations in some cases; counsel and analysts should pull the current CMS guidance.

Federal pharmacy reimbursement rules (federal upper limits for generics, National Average Drug Acquisition Cost survey-based reimbursement, dispensing fees) and federal Drug Utilization Review requirements (prospective DUR at point-of-sale and retrospective DUR via claims review) shape how state pharmacy benefits operate.

Excludable drug categories under federal law

Federal law lists categories of drugs that states may exclude from their Medicaid pharmacy benefit. The principal excludable categories are drugs for anorexia, weight loss, or weight gain (states may cover for documented medical necessity); fertility drugs; cosmetic drugs; cough and cold drugs; smoking cessation drugs (Georgia covers nicotine replacement therapy and varenicline); prescription vitamins and minerals other than prenatal vitamins and fluoride; non-prescription drugs (Georgia covers several OTC drugs with a prescription, including loratadine, omeprazole, and ibuprofen 200mg); DESI drugs; and outpatient drugs for erectile dysfunction (states may elect to cover sildenafil and tadalafil for non-ED uses such as pulmonary arterial hypertension). Georgia has elected to cover several of the optional categories.

Georgia's unified PDL and the pharmacy carve-in model

Before unification, Georgia operated separate pharmacy benefits across the four Georgia Families CMOs. Each CMO maintained its own preferred drug list, its own prior authorization criteria, its own step therapy requirements, and its own pharmacy network. The consequence for members was meaningful variability depending on CMO assignment.

Georgia transitioned to a unified statewide PDL administered by DCH. Under the unified model, DCH and the Georgia Drug Utilization Review Board determine preferred and non-preferred status for each therapeutic class; DCH and the DUR Board publish prior authorization criteria, step therapy requirements, and quantity limits; all four CMOs are required to follow the unified DCH PDL and the unified PA criteria; and CMOs continue to pay for prescriptions dispensed to their members (the pharmacy carve-in model) but cannot impose different PDL rules or PA criteria.

The transition substantially simplified the pharmacy benefit for members and prescribers. A prescription written for a Medicaid member now processes the same way regardless of CMO assignment. PA criteria are uniform across CMOs. The DUR Board's recommendations and the PDL updates apply uniformly across the state. The transition also reduced administrative burden on prescribers, who no longer need to track four separate formularies.

The pharmacy benefit manager

The pharmacy benefit manager that operates the unified pharmacy benefit is Gainwell Technologies, the operational successor to DXC and Magellan Medicaid Administration. Gainwell processes pharmacy claims, applies the PDL and PA criteria, runs the prospective DUR system at point-of-sale, and provides the pharmacy provider help desk at 1-800-766-4456.

The Preferred Drug List structure for Georgia Medicaid prescription drug coverage

The Georgia Medicaid PDL is organized by therapeutic class. For each class, drugs are designated as either preferred or non-preferred.

Preferred drugs are covered without prior authorization. The prescription processes at the pharmacy with no PA requirement, the standard copay applies, and the member receives the drug. Most prescriptions in Georgia Medicaid are for preferred drugs.

Non-preferred drugs require prior authorization. The pharmacist or prescriber must submit a PA request documenting why the non-preferred drug is medically necessary, typically demonstrating failure or contraindication of preferred alternatives. PA-approved non-preferred drugs are dispensed at the standard brand or generic copay.

The PDL is updated by the DUR Board based on current clinical evidence, comparative effectiveness data, manufacturer rebate offerings, and budget considerations. New drugs are added when they receive FDA approval and a manufacturer rebate agreement, and the DUR Board reviews them for placement. Existing drugs may move between preferred and non-preferred status as the evidence base evolves.

Major therapeutic classes on the Georgia PDL include antihypertensives, antidiabetics (with step therapy for newer agents including GLP-1 agonists), lipid-lowering agents, antibiotics and antivirals, mental-health drugs, asthma and COPD drugs, GI drugs, anticoagulants, analgesics with PDMP integration for controlled substances, anticonvulsants, thyroid replacement, contraceptives at $0 copay per ACA mandate, biologics for autoimmune disease, immunosuppressants, oncolytics, and specialty drugs for hepatitis C, cystic fibrosis, multiple sclerosis, gene therapies, and severe asthma.

Prior authorization mechanics under Georgia Medicaid prescription drug coverage

Prior authorization for non-preferred drugs and for certain preferred drugs with clinical criteria (opioids, Schedule II stimulants, biologics, GLP-1 agonists) follows a defined process.

The PA flow:

1. The prescriber writes the prescription.
2. The pharmacist processes the claim at point-of-sale and the claim rejects with a PA-required edit.
3. The pharmacist contacts the prescriber to inform them of the PA requirement.
4. The prescriber submits a PA request to Gainwell via fax (1-866-617-7298), the provider portal, or phone through the pharmacy help desk.
5. The PA request includes the drug, the diagnosis (ICD-10 code), the prior therapy history (which preferred drugs were tried and the outcome), and the clinical rationale.
6. Gainwell reviews the PA against the published criteria.
7. If approved, the PA is entered into the system and the prescription dispenses when the pharmacy resubmits the claim.
8. If denied, the prescriber can appeal or substitute a different drug.

Federal Medicaid pharmacy law requires prompt PA decisions on complete requests; counsel and prescribers should pull the current DCH pharmacy PA page for the operative turnaround standard.

Several mechanisms streamline the process. Auto-PA criteria automatically approve PAs when specified ICD-10 codes appear in the member's claims history (for example, a documented multiple sclerosis diagnosis may auto-approve relevant disease-modifying therapies). Continuity-of-care provisions allow members who are stable on a non-preferred drug at the time they become Medicaid-eligible to continue that therapy with simplified PA approval during the transition. Step-therapy overrides allow prescribers to document why step therapy is inappropriate for a specific member (allergies, prior adverse reactions, contraindications).

Step therapy

Step therapy applies to several classes where less expensive preferred drugs must be tried first. Common Georgia Medicaid step-therapy classes:

• Proton pump inhibitors: preferred PPI (typically omeprazole) before non-preferred PPI.
• SSRIs and SNRIs: preferred SSRI before non-preferred SNRI unless clinical indication supports SNRI first-line.
• Statins: preferred statin (typically simvastatin or atorvastatin) before non-preferred statin or PCSK9 inhibitor.
• Biologics for rheumatoid arthritis: preferred TNF inhibitor (typically adalimumab biosimilar or etanercept) before non-preferred biologic.
• Biologics for inflammatory bowel disease: preferred TNF inhibitor before non-preferred TNF, vedolizumab, or ustekinumab.
• GLP-1 agonists for diabetes: step through metformin, then sulfonylurea or DPP-4 inhibitor, then GLP-1 with PA.

Step therapy can be overridden with documented prior failure or contraindication.

Quantity limits, dispensing supply, and mail-order

Most prescriptions in Georgia Medicaid are dispensed at a multi-week standard supply per fill; pull the current DCH pharmacy services policy for the exact day count.

For many maintenance medications, a 90-day mail-order option is available through the CMO's mail-order pharmacy partner (Express Scripts, CVS Caremark Mail Order, or similar). Mail-order reduces refills, consolidates cost-sharing (one copay per 90-day fill instead of three monthly copays), and supports adherence. Mail-order is typically available for chronic stable medications (antihypertensives, statins, antidiabetics, mental-health maintenance, thyroid replacement) and is not typically available for acute medications, controlled substances, or specialty drugs.

Quantity limits beyond the standard supply apply to specific classes:

• Opioids: morphine milligram equivalent (MME) per day limits and short-supply windows for acute pain prescriptions; PDMP cross-check at each fill.
• Schedule II stimulants for ADHD: maximum supply per prescription with PDMP cross-check; Schedule II prescriptions cannot have refills under federal law and must be written each cycle.
• Benzodiazepines: quantity limits and step therapy through alternative anxiolytics.
• Specialty drugs: typically dispensed as a short-cycle supply at the specialty pharmacy with no mail-order option (specialty pharmacy IS effectively mail-order for these high-cost drugs).

The Georgia Prescription Drug Monitoring Program (PDMP) is integrated with the pharmacy benefit for controlled substances. Pharmacists are required to check the PDMP before dispensing Schedule II opioids and other monitored controlled substances, and prescribers are required to check the PDMP before writing prescriptions for Schedule II controlled substances.

The copay structure for Georgia Medicaid prescription drug coverage

Georgia Medicaid prescription drug copays are nominal, reflecting the federal Medicaid copay constraints that limit cost-sharing for low-income beneficiaries. Pull current copay amounts from DCH or your CMO Member Handbook.

Several categories are exempt from copay:

• Children under 21 (EPSDT prohibition on copays for children)
• Pregnant women (members enrolled in any Medicaid eligibility category have no pharmacy copay during pregnancy)
• Long-term care residents
• Family planning services and supplies (per ACA mandate)
• Emergency services
• Selected preventive services and immunizations

Pharmacies cannot refuse to dispense a prescription if the member cannot pay the copay at the time of dispensing. The member remains responsible for the copay debt to the pharmacy (the pharmacy may bill the member), but the prescription must be dispensed. This federal "cannot deny for inability to pay" rule protects members from being unable to access medication due to inability to pay nominal cost-sharing.

For drugs subject to generic substitution, the pharmacy dispenses the generic and bills the generic copay. If the prescriber has indicated "Dispense as Written" (DAW) and the brand is medically appropriate, the pharmacy dispenses the brand and bills the brand copay.

Specialty pharmacy under Georgia Medicaid prescription drug coverage

Specialty drugs are high-cost, complex-to-administer drugs that require specialized handling, patient education, monitoring, and clinical support. Examples include biologics for autoimmune conditions (adalimumab and biosimilars, etanercept, infliximab, ustekinumab, secukinumab, dupilumab); HIV antiretroviral combinations (Biktarvy, Triumeq, Genvoya, Symtuza, Cabenuva); hepatitis C direct-acting antivirals (Mavyret, Epclusa, Harvoni); cystic fibrosis modulators (Trikafta, Symdeko, Kalydeco); multiple sclerosis disease-modifying therapies; oral oncolytics (imatinib, sunitinib, ibrutinib, palbociclib, osimertinib); transplant immunosuppressants; gene therapies (Luxturna, Zolgensma, Casgevy, Lyfgenia); spinal muscular atrophy drugs (Spinraza, Evrysdi); severe asthma biologics (omalizumab, mepolizumab, benralizumab, dupilumab); hemophilia factor concentrates; pulmonary hypertension drugs; and inherited metabolic disease enzymes.

The Georgia Medicaid specialty pharmacy network includes Walgreens Specialty Pharmacy, CVS Specialty, Accredo (the specialty pharmacy arm of Express Scripts), AllianceRx Walgreens Prime, and select hospital outpatient pharmacies for clinic-administered specialty drugs.

Limited-distribution drugs (drugs the manufacturer makes available only through a designated specialty pharmacy network) are dispensed through the manufacturer's network. Examples include some hemophilia factors, rare-disease drugs, and recently FDA-approved drugs in early launch phase.

Specialty drugs that are clinic-administered (infusions or injections requiring medical supervision) can be dispensed two ways. White-bagging: the specialty pharmacy ships the drug directly to the clinic, which administers it on the visit; the pharmacy bills under the pharmacy benefit. Buy-and-bill: the clinic purchases the drug from a wholesaler and bills under the medical benefit (similar to Medicare Part B physician-administered drugs). The choice is typically made by the CMO and may be specified by drug.

Dual-eligibles and the Medicare Part D carve-out

For Medicare beneficiaries who are also enrolled in Medicaid (dual-eligibles), prescription drug coverage is primarily through Medicare Part D rather than Medicaid. This is one of the few areas where Medicare is the primary payer for a benefit category that Medicaid otherwise covers.

Most prescription drugs are covered through the member's Medicare Part D plan (a Medicare Advantage Prescription Drug plan, a standalone Part D plan, or a dual-eligible special needs plan with integrated Part D). Dual-eligibles receive automatic Extra Help (Low Income Subsidy) for Part D, which substantially reduces or eliminates Part D premiums, deductibles, and copays. Medicaid no longer pays for most prescription drugs for dual-eligibles because Part D is the primary payer.

Medicaid provides wrap-around coverage for drug categories that Part D excludes:

• Some barbiturates and benzodiazepines (Part D coverage has expanded over time)
• OTC drugs that Georgia Medicaid covers with prescription
• Drugs for weight loss when medically necessary (Part D excludes these)
• Fertility drugs
• Vitamins and minerals when Georgia Medicaid covers them
• Cough and cold drugs when Georgia Medicaid covers them

The wrap-around coverage is typically small relative to a dual-eligible's overall drug spending. Most drugs are paid through Part D.

Pharmacy Lock-In Program

Members who exhibit concerning utilization patterns (multiple prescribers for controlled substances, multiple pharmacies, high MME per day, multiple emergency department visits for opioid prescriptions) can be enrolled in a Pharmacy Lock-In Program. Under lock-in, the member is restricted to receiving controlled substance prescriptions from a single designated prescriber and dispensing controlled substances at a single designated pharmacy. The lock-in prevents doctor shopping and opioid diversion while preserving access to legitimately needed medications. Lock-ins are typically reviewed periodically and can be extended or modified.

Naloxone coverage and the Georgia standing order

Georgia Medicaid covers naloxone (Narcan, Kloxxado, generic naloxone hydrochloride) without prior authorization. A Georgia statewide standing order issued by the Department of Public Health allows pharmacists to dispense naloxone to patients, family members, and others at risk of witnessing an opioid overdose, without requiring an individual prescription from a prescriber. For Medicaid members, the standing-order naloxone is covered at no copay.

Several distribution channels supplement the standing order, including Georgia Recovery Initiative, harm reduction programs, and state-funded naloxone purchase programs that distribute naloxone at no cost outside the pharmacy system.

Worked examples of Georgia Medicaid prescription drug coverage

Brenda, 67, Atlanta: diabetes and hypertension routine refills

Brenda has Type 2 diabetes and hypertension. She takes metformin 1000mg twice daily, lisinopril 20mg daily, atorvastatin 40mg daily, amlodipine 10mg daily, and several other medications, totaling 12 prescriptions. She is enrolled in Amerigroup. Her preferred pharmacy is a CVS in her neighborhood. For her acute and PRN medications, she fills at CVS at the standard interval with the generic copay per prescription. For her three most stable maintenance drugs (metformin, lisinopril, atorvastatin), she has switched to 90-day mail-order through Express Scripts, the Amerigroup mail-order partner, which consolidates her cost-sharing and reduces trips to the pharmacy. Generic substitution applies automatically and she has no trouble obtaining her prescriptions.

Marcus, 8, Macon: ADHD treatment with Schedule II stimulant

Marcus is a PeachCare for Kids member with ADHD diagnosed at age 6, treated with methylphenidate ER (Concerta) 36mg daily for the past 2 years with good effect on attention, behavior, and school performance. The prescription is Schedule II and requires PDMP review at each fill; his pediatrician writes a new prescription each cycle (Schedule II prescriptions cannot have refills under federal law). Prior authorization is required because Concerta is non-preferred; the PA documents that Marcus needs the long-acting formulation for school-day coverage and has been stable on Concerta for 2 years. PA is approved for a 12-month duration. As a child under 21, Marcus has no copay.

Tonya, 32, Savannah: pregnancy prescriptions

Tonya is enrolled in Pregnancy Medicaid. She takes a daily prenatal vitamin (no copay because she is pregnant). At her 8-week prenatal visit she reports nausea and vomiting; her OB prescribes ondansetron and a vitamin B6 plus doxylamine combination (Diclegis), both with no copay. At her 14-week visit, the OB prescribes amoxicillin for a urinary tract infection, no copay. At her 28-week visit she has gestational diabetes; insulin glargine is prescribed with no copay. All pregnancy-related prescriptions are at no copay during the pregnancy period and during Georgia's postpartum extension; verify the current Georgia postpartum extension duration with DCH.

David, 55, Atlanta: HIV-positive on antiretroviral therapy

David has been HIV-positive for 15 years and is on a single-tablet regimen of bictegravir/emtricitabine/tenofovir alafenamide (Biktarvy). He is enrolled in Medicaid as an ABD adult through his SSDI eligibility. Biktarvy is a specialty drug dispensed through AllianceRx Walgreens Prime, the specialty pharmacy partner for his CMO. Each fill is shipped to David's home with patient education materials and adherence support, at the standard brand copay. The Ryan White Part B program provides additional medication assistance and clinical support through Mercy Care in Atlanta, with David's primary HIV care team coordinating Medicaid and Ryan White services.

Maria, 45, Albany: depression and diabetes with GLP-1 agonist

Maria has Type 2 diabetes, depression, and obesity. Her current medications include sertraline (preferred SSRI), metformin, glipizide, and sitagliptin (preferred class). Her HbA1c remains above target on the four-drug regimen, and her endocrinologist recommends adding semaglutide as a GLP-1 agonist. Semaglutide requires prior authorization with step therapy documentation. The endocrinologist submits a PA documenting that Maria has tried and failed metformin, sulfonylurea, and DPP-4 inhibitor and has clinical indication for GLP-1. The PA is approved for 12 months. Semaglutide is dispensed through a specialty pharmacy at the brand copay per cycle.

Larry, 41, Columbus: opioid use disorder with buprenorphine

Larry has a history of opioid use disorder and entered medication-assisted treatment 18 months ago at a federally-licensed opioid treatment program. He is enrolled in Georgia Pathways to Coverage. His MAT regimen is buprenorphine plus naloxone (Suboxone) film. Suboxone is on the PDL with PA required for ongoing use beyond an initial induction period. The MAT prescriber submits the PA documenting the diagnosis, the treatment plan, and Larry's stability on the regimen; PA is approved for a 12-month duration. Suboxone is dispensed monthly at his pharmacy at the generic copay (the pharmacy dispenses the generic buprenorphine plus naloxone film). Naloxone (Narcan nasal spray) is also prescribed and dispensed at no copay under the Georgia statewide standing order.

Things commonly missed in Georgia Medicaid prescription drug coverage

1. Georgia has a unified statewide PDL administered by DCH and the DUR Board; all four CMOs follow the same PDL and PA criteria. CMO-specific formularies are not the operating model.
2. CMOs operate a pharmacy carve-in: they pay for member prescriptions but cannot impose different PDL rules or PA criteria.
3. Auto-PA criteria allow approval based on diagnosis codes in claims history for some classes, streamlining the process for members with documented medical conditions.
4. Copays are nominal; children under 21, pregnant women, LTC residents, family planning, and emergency services are exempt.
5. Pharmacies cannot refuse to dispense if a member cannot pay the copay at the time of dispensing.
6. The standard dispensing supply is multi-week; 90-day mail-order is available for many maintenance medications through CMO mail-order partners.
7. Dual-eligibles get most prescription drugs through Medicare Part D, not Medicaid. Medicaid provides only wrap-around coverage for Part D-excluded categories.
8. Naloxone is covered without PA and is available through the Georgia statewide standing order at no copay for Medicaid members.
9. Family planning drugs and supplies are no-copay with confidentiality protections.
10. ADHD Schedule II stimulants and opioids require PDMP review before dispensing.
11. Specialty drugs are dispensed through a limited network of specialty pharmacies (Walgreens Specialty, CVS Specialty, Accredo, AllianceRx).
12. Some OTC drugs are covered with a prescription (loratadine, omeprazole, ibuprofen, others).
13. Compounded prescriptions require PA.
14. The pharmacy lock-in program restricts members with concerning utilization patterns to a single prescriber and pharmacy for controlled substances.

Frequently Asked Questions

A few more common questions:

Does Georgia Medicaid cover GLP-1 agonists like Ozempic or Wegovy? Georgia Medicaid covers GLP-1 agonists for Type 2 diabetes (Ozempic, Trulicity, Rybelsus, Mounjaro) with prior authorization documenting step therapy through metformin, sulfonylurea, and DPP-4 inhibitor. Weight-loss-only indications (Wegovy, Zepbound) are excluded under federal law, which excludes drugs for weight loss from mandatory Medicaid coverage. A member with both Type 2 diabetes and obesity can have their GLP-1 covered for the diabetes indication.

Where can I get naloxone if I'm worried about an opioid overdose in my family? Naloxone is available in Georgia under a statewide standing order issued by the Department of Public Health. You can walk into any Georgia pharmacy and request naloxone without a prescription from your prescriber; for Medicaid members, naloxone is covered at no copay under the standing order. Additional channels include Georgia Recovery Initiative, harm reduction programs, and state-funded naloxone purchase programs.

What if my pharmacy says my prescription is not covered? Ask the pharmacist what the specific issue is. Common issues are: the drug is non-preferred and requires PA; the drug has a step therapy requirement; the drug has a quantity limit; or the drug is excluded under federal law. If the issue is PA-required, the prescriber can submit a PA via fax to 1-866-617-7298. If the prescription remains denied after PA review, you can appeal through the CMO's appeals process or through Medicaid fair hearing. The DCH pharmacy provider help desk at 1-800-766-4456 and the CMO member services lines can also troubleshoot specific situations.

Contacts for Georgia Medicaid prescription drug coverage

For more on Georgia's broader Medicaid benefits, see Brevy's guide to Georgia Medicaid covered services, Georgia Medicaid managed care plans, and Georgia Medicaid behavioral health coverage. For pregnancy specifics, see Georgia Medicaid pregnancy coverage and the postpartum coverage extension. For dual-eligible coordination, see Georgia Medicare vs Medicaid. For copay specifics, see Georgia Medicaid cost-sharing and copays.

Find personalized help navigating Georgia Medicaid prescription drug coverage at brevy.com.