• Are pharmacists’ professional services covered by PUBLIC/GOVERNMENT insurance (i.e. Medicaid)?

    An important aspect of whether individual pharmacists will participate in pharmacy-based buprenorphine induction and maintenance services is the extent to which the pharmacist will receive health insurance reimbursement for clinical services provided. Pharmacists are not universally recognized as healthcare providers eligible for reimbursement by Medicare Plan B (medical insurance not including prescription drug coverage), state Medicaid programs, or commercial insurance plans. While pharmacist “provider status” under Medicare is function of federal law, state laws and regulations can allow or require state Medicaid programs and commercial insurers to cover a limited or full range of pharmacist services.

    Accordingly, this question asks what services provided by a pharmacist do state Medicaid programs cover. To answer this question, LAPPA reviewed state laws/regulations governing Medicaid benefits and commercial insurance plans, as well as two recent surveys that proved very useful (see references below). Although the question focuses on coverage under state Medicaid programs, where state laws/regulations/policies address commercial insurance coverage requirements, the response notes this as well.

    References: 

  • Are pharmacists’ professional services covered by PUBLIC/GOVERNMENT insurance (i.e. Medicaid)?

    • 15 states where pharmacists, pharmacists with advanced certification (e.g., clinical pharmacist practitioners) or pharmacists acting under CPAs are full providers under state Medicaid programs; Alaska, Colorado, Delaware, Idaho, Maryland, Missouri, Nevada, New Mexico, North Carolina, Ohio, Oregon, Tennessee, Virginia, Wisconsin, and Wyoming.

    • 25 states and the District of Columbia where state Medicaid covers a limited set of pharmacist services; Alabama, Arkansas, California*, Illinois, Indiana, Iowa, Kansas, Louisiana, Massachusetts, Michigan, Minnesota, Mississippi, Montana, Nebraska, New Hampshire, New Jersey, New York, North Dakota, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Utah, Vermont, Washington*, and the District of Columbia.

      • In California and Washington, commercial insurance plans must reimburse pharmacist services like other healthcare providers.

    • Three states where there is no requirement to cover pharmacist clinical services under state Medicaid but pharmacists are full providers under commercial insurance plans; Kentucky, Texas, and West Virginia.

    • Seven states and Puerto Rico where no pharmacist clinical services appear to be covered under state Medicaid programs or commercial plans; Arizona, Connecticut, Florida, Georgia, Hawaii, Maine, Puerto Rico, and South Dakota.

    More details about each state Medicaid program’s coverage can be found in the individual state charts.