PHLP often hears from clients who pay out of pocket for over-the-counter (OTC) medications as well as from social workers and advocates seeking information about programs that cover them at minimal or no cost.
Medicaid, Medical Assistance in Pennsylvania and referred to here as MA, covers OTC medications. A list of 15 medication categories can be found at 55 PA Code § 1121.53 (d), but the list is not exhaustive or comprehensive.
In general, MA covers OTC medication when three requirements are met:
(1) it is prescribed by a doctor,
(2) the manufacturer participates in the Medicaid Drug Rebate Program, and
(3) it falls into a covered category on the list.
Some examples of covered categories include analgesics such as aspirin or ibuprofen; antacids; laxatives and stool softeners; and certain vitamins and minerals. Store brands of OTC medications (e.g., CVS, Rite Aid brands) are NOT covered by MA because of the second requirement noted above.
Cough and cold medications are only covered for people under age 21. At publication of this article, Pennsylvania Medicaid officials had requested permission from the federal government to expand coverage for OTC cough and cold medications for adults ages 19 to 64 during the COVID emergency. PHLP expects this request will be granted.
Medicare recipients who also have MA coverage (dual eligibles) can use their MA coverage for OTC medications. This is because OTC medications are excluded from the Medicare Part D benefit. Medicare recipients enrolled in a Medicare Advantage Plan or a Special Needs Plan should ask their plan about coverage for OTC medications because these may be covered as an extra benefit.
Most people on MA in Pennsylvania (including dual eligibles) now receive their MA services through managed care plans under the HealthChoices or Community HealthChoices programs. Before paying for OTC medications out of pocket, MA enrollees should contact their managed care plan to find out: (i) which OTC medications are covered under their plan, (ii) if a specific OTC medication that they take is covered, and (iii) if a particular medication is not covered, whether an alternate medication can be covered.
MA enrollees in the MA fee-for-service system (i.e., the ACCESS card) can contact Pennsylvania’s MA Recipient Services at 1-800-537-8862 (option 1) to find out which OTC medications are covered Pharmacies can also reach out to the enrollee’s managed care plan or the MA Pharmacy Services department if they have questions about coverage or how to bill for an OTC medication.
People on MA, or their advocates, who are having problems getting OTC medications can call PHLP’s Helpline at 1-800-274-3258.