Medicaid Coverage of Aldara
Because brand-name and generic versions of Aldara are expensive, people using this medication may wonder if Medicaid will cover the cost. However, Medicaid benefits vary significantly from state to state. To find out if Medicaid will provide coverage for Aldara, consult your pharmacist or your state's Medicaid program.
An Overview of Aldara and MedicaidAldara® (imiquimod cream) is a prescription medication approved to treat actinic keratosis (a type of precancerous skin lesion), basal cell carcinoma (a type of skin cancer), and genital or perianal warts. It is an expensive medication, even in generic form. As a result, many people wonder if Aldara is covered by Medicaid.
Medicaid BasicsMedicaid is a public insurance program that provides health benefits to low-income individuals. It is jointly funded by federal and state money. There are certain guidelines that all Medicaid programs must meet, but largely states determine most of the details of their particular programs.
As a result, Medicaid benefits vary largely from state to state. There is no federal requirement for states to cover prescription drugs, although states may choose to do so. States may also choose which drugs to cover and which ones to exclude. These "formularies" (lists of covered and not-covered drugs) can change frequently.
Does My State's Medicaid Cover Aldara?Because every state is different, and because formularies change frequently, you must contact your state's Medicaid program to answer this question. Also, local pharmacists may know the answer to this question, as they deal with Medicaid on a daily basis.
Do not rely on the experience of other people who have used Aldara to decide if this medicine is covered. This is particularly true for people who live in other states (coverage varies by state), or those who used Aldara in the distant past (as the drug is now generic and is more likely to be covered). Even prescribers can be wrong on this issue because they rely mostly on reports of drug coverage from their patients. It is best to check with Medicaid or your pharmacist for a definitive answer.
Often, Medicaid covers certain expensive medications only under certain conditions. In these situations, "prior authorization" is necessary (the exact steps needed to obtain prior authorization vary by state). For instance, a Medicaid program might decide to pay for Aldara for basal cell carcinoma only, but not for actinic keratosis or genital warts. In this situation, your healthcare provider would need to document for Medicaid that you are using the medication for basal cell carcinoma in order to obtain prior authorization.
Essentially, figuring out whether your Medicaid will cover Aldara is the same process that would occur for any insurance. Just like insurance plans, Medicaid plans vary, although there is less variation. Keep in mind that Medicaid is not the same as Medicare. If you are covered under Medicare, you will need to contact your Medicare Part D plan to determine coverage.