A drug Georgia Medicaid covers can still be rejected at the pharmacy counter, because a drug that isn't preferred on your plan's list needs prior authorization (PA) first. Georgia Medicaid doesn't run one drug list for everyone. Which list applies depends on how you're enrolled: fee-for-service members fill through OptumRx, the state's pharmacy benefits manager for that program, and members of a Georgia Families Care Management Organization (CMO) fill through their plan, which keeps its own drug formulary. So the first thing to find out about any drug is which plan you're in and what that plan's list says about it.

In This Guide

Why a covered drug still gets rejected at the pharmacy

On Medicaid's traditional benefit list, outpatient prescription drugs are an optional benefit for adults, so coverage turns on each state's own plan; adults in a Medicaid expansion group get benchmark coverage that must include prescription drugs, and children under 21 reach prescribed drugs through Medicaid's EPSDT benefit. Georgia does cover outpatient drugs: DCH runs a fee-for-service outpatient pharmacy program, with OptumRx as its pharmacy benefits manager. So at the counter, the real question is usually whether a drug is preferred.

Federal Medicaid law lets a state steer prescribing with a Preferred Drug List and prior authorization, but only if the state's PA system responds to a request within 24 hours (a response, not necessarily a final approval or denial) and provides for at least a 72-hour supply of a covered drug in an emergency situation. In Georgia, the list that does the steering depends on your plan: each Georgia Families CMO has its own formulary, and the fee-for-service program has its own drug list. A drug your plan lists as preferred fills with no extra step. A non-preferred drug can still be covered, but the pharmacy claim rejects with a "prior authorization required" message until a prescriber documents why that drug is the right one.

Behind that point-of-sale check sits the federal Drug Utilization Review (DUR) requirement. Every state Medicaid program must run a DUR program for covered outpatient drugs, combining prospective review (a safety check before each fill) and retrospective review (claims analysis to catch overuse and unsafe prescribing). That's why a claim can reject for a reason other than non-preferred status: the safety check before the fill can flag it too.

Which Georgia Medicaid drug list applies to you

Georgia Medicaid's drug lists sort drugs into two groups. A preferred drug fills without prior authorization. A non-preferred drug needs prior authorization before the pharmacy can fill it. What differs from one member to the next is whose list does the sorting:

How you're enrolled Who processes your prescriptions Whose drug list applies
Fee-for-service Medicaid OptumRx, DCH's pharmacy benefits manager for fee-for-service The fee-for-service program's list
Amerigroup Community Care Amerigroup or the pharmacy benefits manager it contracts with Amerigroup's formulary
CareSource CareSource or the pharmacy benefits manager it contracts with CareSource's formulary
Peach State Health Plan Peach State or the pharmacy benefits manager it contracts with Peach State's formulary

DCH says OptumRx processes all fee-for-service outpatient pharmacy claims at the point of sale and pays enrolled pharmacies weekly. CMO members get their pharmacy benefit through their CMO or the pharmacy benefits manager it subcontracts, not through OptumRx, and DCH's Georgia Families page links a separate drug formulary for each CMO. Gainwell Technologies, DCH's fiscal agent for the Georgia Medicaid Management Information System (GAMMIS) since 2010, staffs the GAMMIS customer-service lines; DCH names OptumRx, not Gainwell, as the fee-for-service pharmacy benefits manager. A fuller breakdown is in the Georgia Medicaid pharmacy benefit manager guide.

A January 2023 study by Georgia's Office of Health Strategy and Coordination counted four drug lists in Georgia Medicaid: one for each of the three CMOs and one for fee-for-service. It found the plans weren't required to follow the same list, and that each one negotiated rebates and preferred drug placement with drug manufacturers on its own. The study was commissioned to weigh replacing that structure, so treat it as background and check your plan's current formulary for the drug you care about.

Two practical consequences follow. First, the same drug can be preferred on one list and non-preferred on another, so a drug that filled easily before may need prior authorization after you move between fee-for-service and a CMO, or from one CMO to another. Second, the plans themselves may change. While a reprocurement of the CMO contracts sits in the protest phase, DCH says it will extend the current three CMOs' contracts through June 30, 2027, unless a new award is issued first; as of September 4, 2026, no move to new plans had been scheduled. If your plan changes, pull the new plan's formulary before your next refill.

If a drug isn't on your plan's list at all. Federal law lets a state Medicaid formulary leave out a drug for a condition only if that drug has no significant, clinically meaningful advantage over the drugs on the formulary and there's a public written explanation of the exclusion, and the state plan must still allow an excluded drug to be covered through prior authorization. Some classes can't be excluded from coverage at all, including smoking-cessation drugs, barbiturates, and benzodiazepines. Those are rules on the state program, so ask your plan how it handles a drug its formulary leaves out. CareSource, for one, tells members they can ask it to cover a drug that isn't on its preferred list, which it calls asking for an exception.

How to get a non-preferred drug approved

When your plan's list puts a drug behind prior authorization, the request usually moves through these steps. The forms, portal, and criteria belong to whoever runs your pharmacy benefit, so they differ between fee-for-service and each CMO.

1
Step 1

The prescriber writes the prescription

Your doctor prescribes the drug as usual, whether it is preferred or non-preferred.

2
Step 2

The pharmacy submits the claim and it rejects

The claim comes back with a "prior authorization required" edit, so nothing dispenses yet.

3
Step 3

The pharmacy tells the prescriber a PA is needed

The pharmacist flags the rejection so the prescriber's office can start the paperwork.

4
Step 4

The prescriber submits the PA

They send it to whoever administers the member's pharmacy benefit (OptumRx for fee-for-service members, or the member's CMO and its pharmacy benefits manager) through that administrator's own channels.

5
Step 5

The PA documents medical necessity

It includes the drug, the diagnosis (ICD-10 code), prior therapy history (which preferred drugs were tried and what happened), and the clinical rationale.

6
Step 6

The reviewer checks the PA against the plan's criteria

The request is measured against the prior authorization criteria that the member's plan applies to that drug.

7
Step 7

If approved, the drug dispenses

The pharmacy resubmits the claim and the medication fills.

8
Step 8

If denied, the prescriber can appeal or switch

They can appeal the decision or move the member to a different, covered drug.

Federal law lets a state require prior authorization only if its PA system responds to a request within 24 hours, and that is a response, not necessarily a final decision. If a prescriber judges that a preferred drug would work less well for you or cause adverse effects, say so in the request: federal rules also use that judgment to limit the copay on a non-preferred drug, as the cost section below explains.

If a denial stands after PA review, ask your plan (or, for fee-for-service, Georgia Medicaid Member Services) how to appeal it. Your prescriber's office can call DCH Provider Services, and your CMO's member services line can help you troubleshoot a specific rejection.

The 72-hour emergency supply

This is worth knowing before you reach the counter, because it is narrower than it is often described. Federal Medicaid law lets a state require prior authorization only if its PA system provides for dispensing at least a 72-hour supply of a covered outpatient drug in an emergency situation, as the federal Secretary of Health and Human Services defines one. The trigger is the emergency itself, not a PA that is slow or stuck, and the rule does not reach the drug classes federal law lets a state exclude or restrict. The statute also says nothing either way about whether these conditions bind a managed care plan's own PA process, so a Georgia Families member should ask the plan how it handles an urgent fill. If you need a drug urgently and the PA has not cleared, tell the pharmacist it is an emergency and ask whether an emergency supply can be dispensed, rather than leaving without asking. The same statute that authorizes prior authorization is what bounds it with this emergency-supply condition and the 24-hour response rule.

What you pay at the pharmacy

Georgia Medicaid drug copays are small. DCH's Medicaid copay schedule prices pharmacy copays on the cost of the drug: $0.50 when the drug costs $10.00 or less, $1.00 for $10.01 to $25.00, $2.00 for $25.01 to $50.00, and $3.00 for $50.01 or more. Each Georgia Families plan also publishes its own copay schedule, and the plans' schedules are not identical to each other or to DCH's list; CareSource, for example, lists $0.50 for a preferred drug and a cost-based copay for a non-preferred one. Check the schedule for the plan you are in. Those amounts sit well under the federal ceiling. The table in 42 CFR 447.53(b) lists $4 for a preferred drug and $8 for a non-preferred drug for members at or below 150% of the federal poverty level, but those are base amounts that have been indexed upward every year since October 2015, so the federal maximum today is higher than the printed figure. Total cost sharing for the household is also capped: Medicaid premiums and cost sharing may not exceed 5% of family income.

Two protections matter most. First, several groups are exempt from copays, though federal rules let a state charge even an exempt member the copay for a non-preferred drug. That non-preferred charge has a limit of its own: when your prescriber determines that a preferred drug in the same class would be less effective for you or cause adverse effects, federal rules require the state to have a timely process that holds your copay to the preferred-drug amount. Second, DCH states that if you cannot pay the copayment, you may still receive services. The copay is not forgiven, though: Medicaid.gov says enrollees may be held liable for unpaid copayments.

Situation What you pay Source of the rule
Drug costing $10.00 or less $0.50 DCH Medicaid copay schedule
Drug costing $10.01 to $25.00 $1.00 DCH Medicaid copay schedule
Drug costing $25.01 to $50.00 $2.00 DCH Medicaid copay schedule
Drug costing $50.01 or more $3.00 DCH Medicaid copay schedule
Members under 21, pregnant members, nursing home residents, hospice members, Breast and Cervical Cancer program members, American Indians and Alaska Natives No copay, per the plans' schedules; confirm with your plan CareSource and Peach State member schedules
Cannot pay at the counter You may still receive services; you can still be held liable for the copay DCH copay schedule; Medicaid.gov

The exempt list in that table is the plans' statement: DCH's own schedule page says only that Pathways members under 21 pay no copay, so confirm an exemption with your plan or DCH before counting on it. Pregnancy-related services, including pregnancy-related drugs, are exempt from Medicaid cost sharing under federal law, so a member who is pregnant pays no copay for those prescriptions, with one boundary: federal rules let a state charge the non-preferred-drug copay even to a member who is otherwise exempt.

Does Georgia Medicaid cover Ozempic or Wegovy?

It depends on your plan's drug list. Federal Medicaid law lets a state put any covered outpatient drug behind prior authorization, and lets it exclude or otherwise restrict the drug classes listed in section 1927(d)(2) of the Social Security Act. In Georgia, the list that applies is your CMO's formulary or the fee-for-service program's list, so the same GLP-1 drug can be handled differently from one plan to the next. Before the prescription is written, ask the prescriber to check your plan's formulary for the specific drug and the reason it's being prescribed, and to ask the plan whether prior authorization applies.

If you have Medicare and Medicaid

If you are enrolled in both Medicare and Medicaid (a dual-eligible), Medicare is the primary payer and pays first, and Medicaid pays second. For prescriptions, that means your Medicare Part D coverage (a standalone drug plan, a Medicare health plan that includes drug coverage, or a dual-eligible special needs plan) is the card to show first. People with full Medicaid coverage get Extra Help, the Part D Low-Income Subsidy, automatically, without a separate application.

If your Part D plan will not cover a drug, ask Georgia Medicaid member services or your plan whether Medicaid covers it, rather than assuming either way.

Worked examples

These illustrative scenarios show how plan drug lists, prior authorization, and copays play out. They're hypothetical composites, not real members, and each plan's list and copays can differ from what's shown here.

Maintenance refills on a preferred list

A member with Type 2 diabetes and hypertension takes several stable maintenance drugs. All are preferred on her plan's list, so they fill with no prior authorization. Under DCH's cost-based schedule, a drug costing $10.00 or less carries a $0.50 copay, so inexpensive generics cost her very little; her plan's own schedule is the one to check.

A non-preferred ADHD stimulant for a child

A child on PeachCare for Kids takes a long-acting stimulant for ADHD. His plan lists the drug as non-preferred, so a prior authorization documents that he needs the long-acting form for school-day coverage and has been stable on it. The pediatrician writes a new prescription each cycle. PeachCare for Kids waives copays only for children under six (and for children in foster care and American Indian or Alaska Native children), so at his age his family pays a small cost-based copay for this non-preferred drug.

Pregnancy prescriptions at no copay

A member on Pregnancy Medicaid fills a prenatal vitamin, an anti-nausea drug, and later an antibiotic and insulin for gestational diabetes. Pregnancy-related prescriptions are exempt from cost sharing, so she pays no copay for them during the pregnancy, unless one is a non-preferred drug, which federal rules let a state charge for even when a member is otherwise exempt.

A non-preferred diabetes drug that needs prior authorization

A member with Type 2 diabetes is on several preferred diabetes drugs, but her blood sugar is still above target. Her endocrinologist prescribes a GLP-1 drug that her plan lists as non-preferred. The prior authorization records the drugs she has already tried and why she needs this one, the plan approves it, and the pharmacy fills it at her plan's copay.

Frequently Asked Questions

Is there one Georgia Medicaid Preferred Drug List?

No. Which drugs are preferred depends on your plan. Fee-for-service members fill through OptumRx under the fee-for-service program, and each Georgia Families CMO keeps its own formulary, which DCH links from its Georgia Families page. The three current CMOs are Amerigroup Community Care, CareSource, and Peach State Health Plan. Check the list for the plan you're in.

My drug was rejected at the pharmacy. What do I do?

Ask the pharmacist what the rejection says. Often the drug is non-preferred on your plan's list and needs a prior authorization; another possibility is the safety review that runs before each fill. If a PA is needed, your prescriber submits it to whoever runs your pharmacy benefit (OptumRx if you are fee-for-service, or your CMO and its pharmacy benefits manager). If it is an emergency, tell the pharmacist: federal law lets a state require prior authorization only if its PA system provides for dispensing at least a 72-hour supply of a covered drug in an emergency situation.

How fast does a prior authorization have to be decided?

Federal Medicaid law sets a response time, not a decision deadline: a state may require prior authorization only if its PA system responds to a request within 24 hours, and that response need not be a final approval or denial. The same provision requires the system to provide for dispensing at least a 72-hour supply of a covered drug in an emergency situation. Ask the plan how long an approval lasts and how to renew it.

How much do prescriptions cost under Georgia Medicaid?

Copays are small. Under DCH's Medicaid copay schedule, a prescription copay runs from $0.50 to $3.00 depending on what the drug costs, though each Georgia Families plan publishes its own schedule. Federal rules also cap a household's total premiums and cost sharing at 5% of family income. The plans list members under 21, pregnant members, nursing home and hospice residents, Breast and Cervical Cancer program members, and American Indians and Alaska Natives as exempt, and DCH says that if you cannot pay the copayment, you may still receive services.

I have Medicare and Medicaid. Where do I get my prescriptions?

Medicare pays first for someone with both Medicare and Medicaid, so show your Medicare Part D card first. People with full Medicaid coverage get Extra Help, the Part D Low-Income Subsidy, automatically, without a separate application. If Part D will not cover a drug, ask Georgia Medicaid or your plan whether Medicaid does.

Does Georgia Medicaid cover Ozempic or Wegovy?

It depends on your plan's drug list, so ask your plan before the prescription is written. Federal law lets a state put a covered drug behind prior authorization and exclude or otherwise restrict the drug classes listed in section 1927(d)(2). In Georgia, each CMO's formulary and the fee-for-service list can treat the same drug differently.

Who to call

Georgia Medicaid Member Services DCH's Medicaid Member Services line, the GAMMIS Member Call Center for general questions about your benefits, ID card, and providers. Eligibility questions go instead to the Gateway Customer Service Center at 1-877-423-4746. 1-866-211-0950https://www.medicaid.gov/about-us/where-can-people-get-help-medicaid-chip medicaid.georgia.gov
DCH Provider Services The line DCH lists for Georgia Medicaid providers. It is for your prescriber or pharmacist, not for members, so pass it along if their office has a question about a rejected claim. 1-800-766-4456https://www.medicaid.gov/about-us/where-can-people-get-help-medicaid-chip dch.georgia.gov
Amerigroup Community Care Member Services Member services for Amerigroup enrollees; ask about your plan's pharmacy benefit and drug formulary, a rejected drug, or a pending prior authorization. Call the member services number printed on your plan ID card. www.myamerigroup.com/ga
Peach State Health Plan Member Services Member services for Peach State enrollees; ask about your plan's pharmacy benefit and drug formulary, a rejected drug, or a pending prior authorization. Call the member services number printed on your plan ID card. www.pshpgeorgia.com
CareSource Georgia Member Services Member services for CareSource enrollees; ask about your plan's pharmacy benefit and drug formulary, a rejected drug, or a pending prior authorization. Call the member services number printed on your plan ID card. www.caresource.com/ga

Learn More

MedicaidGeorgia Medicaid pharmacy benefit managerWho runs your Georgia Medicaid drug benefit, why a prescription gets denied, the 72-hour emergency supply rule, and how to appeal a Medicaid drug denial. MedicaidGeorgia Medicaid prior authorization processGeorgia Medicaid prior authorization in 2026: federal framework, FFS vs CMO pathways, standard and expedited timelines, peer-to-peer reviews, and appeals. MedicaidGeorgia Medicaid mental health drugsDoes Georgia Medicaid cover antidepressants and antipsychotics? How the PDL, prior authorization, the 72-hour emergency supply, and Part D rules work in 2026. MedicaidGeorgia Medicaid cost-sharing and copaysGeorgia Medicaid copays in 2026: drugs from $0.50, $3 non-emergency ER, $12.50 inpatient, who pays nothing, and how to dispute a wrong charge. MedicaidGeorgia Medicaid covered servicesWhat Georgia Medicaid covers in 2026: hospital and doctor visits, prescriptions, dental, behavioral health, long-term care, and EPSDT for children. MedicaidGeorgia Medicaid dual-eligiblesGeorgia dual eligible programs in 2026: full Medicaid and the four Medicare Savings Programs, income and asset limits, applying via Georgia Gateway, and D-SNPs.

Find personalized help understanding your Georgia Medicaid drug 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.

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