Medicaid — state by state
Drug spend · 2025
What Medicaid actually paid for outpatient prescription drugs, from CMS State Drug Utilization Data — aggregated across every state and quarter. Below the spending: the 50-state dispensing-fee survey and the deep-dive state reports. New to how Medicaid pricing works? Read the explainer.
ⓘ How this was built
- CMS State Drug Utilization Data (SDUD)
- FDA NDC Directory (openFDA) for product names
Totals sum CMS-reported Medicaid outpatient reimbursement rows per NDC, state, and quarter for the latest complete year. Amounts are pre-rebate (gross). Aggregation only — no modeling.
Pipeline and calculations built by Claude (Fable 5) from the public datasets above. Educational only — verify against primary sources before acting.
Every figure on this page is gross— what Medicaid paid pharmacies before manufacturers rebate money back. Unlike Medicare Part D's confidential rebates, Medicaid's are set in law: at least 23.1% of manufacturer price on brands and 13% on generics, plus a penalty when a price outruns inflation. Those penalties are large — MACPAC measured federally required brand rebates averaging 61.6% of gross. 89% of this spending is brand-name drugs, which is why the estimated cut is so deep.
Spend by state
Expand a state to see the drugs it spends the most on.
Source: CMS State Drug Utilization Data · Medicaid-paid amount, all states and quarters of 2025. Suppressed small-cell values are excluded, so totals are slight underestimates.
State Reports: the dispensing-fee survey
The dispensing fee, state by state: what the federal Medicaid file includes — and where it doesn't
CMS's State Drug Utilization Data is the only national record of what Medicaid pays pharmacies. Our Oklahoma report found that state's managed-care rows omit the dispensing fee entirely — payments that pharmacists confirm receiving are simply absent from the federal record. This page runs the same test on every state: reported generic payment above NADAC acquisition cost, per prescription. A margin near a typical dispensing fee (~$8–12) is consistent with fee-included reporting; a margin near zero is consistent with ingredient-only reporting.
The short version
Across the 36 states with enough managed-care data to judge (latest four quarters through 2026 Q1): 21 report managed-care margins consistent with the dispensing fee included, 4 report margins consistent with the dispensing fee missing, and 7 flipped mid-series — the Oklahoma pattern, where reporting changed from one quarter to the next. The same federal file, describing the same kind of payment, means different things depending on the state — which is exactly what a national dataset must not do.
Every state, judged by its own filings
Medicaid pharmacy payment is designed the same way everywhere: repay the pharmacy what the drug cost to buy, plus a fixed dispensing fee for the work of filling the prescription. Each state sets its own dispensing fee and publishes it — that is the published dispensing fee column, and every state's is roughly $8 to $12 (the volume tiers some states pay their smallest pharmacies run higher).
One legal fact keeps this whole table honest: that published dispensing fee binds only the state's own fee-for-service program. Federal rule requires the state to pay acquisition cost plus the dispensing fee where it pays pharmacies directly — but managed-care plans and their PBMs negotiate their own pharmacy rates, and in most states nothing requires them to pay the published dispensing fee. A managed-care margin below the dispensing fee is therefore usually lawful: it is the gap between what the state says dispensing costs and what plans actually pay for it. Closing that gap is what the current wave of floor legislation is about — Louisiana wrote its fee-for-service rate into statute for MCOs, Mississippi mandated the fee-for-service formula outright (its filings match the dispensing fee to the penny), and bills pending in South Carolina, Illinois, and New Jersey would do the same. A few states went further still and took the checkbook back entirely — the pharmacy carve-out, explained.
The two margin columns measure what the filings actually show: reported payment minus the drugs' purchase cost, per prescription — the pharmacy's gross profit per prescription, before wages or rent. If payments follow the design and the filings are complete, the margin should land near the published dispensing fee — so read every row as margin next to published dispensing fee. A margin of $5 or more can only happen if a real dispensing fee is in the reported payments (“fee included”). A margin under $2 means the filings show almost nothing above drug cost — no state's dispensing fee is remotely that low, so the dispensing fee cannot be in them (“fee missing”). In between, we say “unclear” rather than guess. Verdicts are about the reporting, not the state's honesty — in Oklahoma, pharmacists confirmed the dispensing fee is really paid, just absent from the federal file.
ⓘ How this was built
- CMS State Drug Utilization Data 2022-2026, all states, FFSU vs MCOU
- CMS NADAC quarterly per-NDC averages
- FDA NDC Directory (ANDA = generic)
Per state, quarter, and payment system: (total amount reimbursed − units × quarterly NADAC) ÷ prescriptions, over generic NDCs with a NADAC price (94-97% of generic dollars in most states). Verdicts over the latest four quarters: ≥$5/rx reads as fee-included, <$2 as fee-missing, between as unclear; 'changed mid-series' marks a quarter-to-quarter crossing between those bands. States with essentially no managed-care pharmacy claims (under 1,000 in the window) never put the benefit into managed care and are labeled exactly that; under 10,000 is not judged; and states whose managed-care bucket holds under 5% of their generic dollars are labeled residual (carve-out) rather than judged. Neither side of SDUD itemizes the dispensing fee — the margin is all that is measurable.
Pipeline and calculations built by Claude (Fable 5) from the public datasets above. Educational only — verify against primary sources before acting.
| Stateⓘ | Payment modelⓘ | FFS $/rxⓘ | MCO $/rxⓘ | Published dispensing feeⓘ | MCO payment vs published FFS feeⓘ | What the filings showⓘ |
|---|---|---|---|---|---|---|
| Alaska | FFS only | $15.07 | — | — | — | Alaska Medicaid pays pharmacies only through fee-for-service, so the FFS column is the whole story: pharmacies averaged $15.07 profit per generic prescription over the drug's cost (before wages and overhead). |
| Alabama | FFS only | $9.09 | — | — | — | Alabama Medicaid pays pharmacies only through fee-for-service, so the FFS column is the whole story: pharmacies averaged $9.09 profit per generic prescription over the drug's cost (before wages and overhead). |
| Arkansasfull report | 20% MCO 80% FFS | $9.60 | $6.99 | $10.50 | −$3.51 | Plans reported paying pharmacies $6.99 per generic prescription above drug cost — enough that the reported payments must include a dispensing fee, not just the drug (against the $10.50 dispensing fee the state publishes). |
| Arizonafull report | 99% MCO 1% FFS | — | $8.09 | $10.11 | −$2.02 | Plans reported paying pharmacies $8.09 per generic prescription above drug cost — enough that the reported payments must include a dispensing fee, not just the drug (against the $10.11 dispensing fee the state publishes). |
| Californiafull report | Carve-out: drugs paid FFS | $10.74 | — | $10.05 | — | Medi-Cal Rx: on January 1, 2022, California removed the pharmacy benefit from its managed-care plans entirely and began paying pharmacies directly, statewide. The few managed-care rows left in the file are residue, so no margin is shown or judged. |
| Coloradofull report | 6% MCO 94% FFS | $7.25 | $8.72 | $8.72 | +$0.00 | Plans reported paying pharmacies $8.72 per generic prescription above drug cost — enough that the reported payments must include a dispensing fee, not just the drug (against the $8.72 dispensing fee the state publishes). |
| Connecticut | FFS only | $10.58 | — | — | — | Connecticut Medicaid pays pharmacies only through fee-for-service, so the FFS column is the whole story: pharmacies averaged $10.58 profit per generic prescription over the drug's cost (before wages and overhead). |
| District of Columbiafull report | 88% MCO 12% FFS | $9.60 | $5.36 | $11.15 | −$5.79 | Plans reported paying pharmacies $5.36 per generic prescription above drug cost — enough that the reported payments must include a dispensing fee, not just the drug (against the $11.15 dispensing fee the state publishes). |
| Delawarefull report | 100% MCO 0% FFS | — | $6.09 | $10.00 | −$3.91 | Plans reported paying pharmacies $6.09 per generic prescription above drug cost — enough that the reported payments must include a dispensing fee, not just the drug (against the $10.00 dispensing fee the state publishes). |
| Floridafull report | 97% MCO 3% FFS | — | $5.63 | $10.24 | −$4.61 | Plans reported paying pharmacies $5.63 per generic prescription above drug cost — enough that the reported payments must include a dispensing fee, not just the drug (against the $10.24 dispensing fee the state publishes). |
| Georgiafull report | 58% MCO 42% FFS | $8.77 | $1.07 | $10.63 | — | Plans reported paying just $1.07 above drug cost — essentially the drug alone; the $10.63 dispensing fee the state publishes is nowhere in these filings. Most likely the plans do pay a dispensing fee that simply goes unreported in CMS's State Drug Utilization Data — in Oklahoma, the one state where this was ground-truthed, pharmacists confirmed exactly that. |
| Hawaiifull report | 98% MCO 2% FFS | — | $5.47 | $10.76 | — | The filings jumped between fee-included and near-zero levels in 2025 Q2; the latest four quarters average $5.47 above drug cost — the full report shows the break. |
| Iowafull report | 99% MCO 1% FFS | — | $5.21 | $10.07 | — | The filings jumped between fee-included and near-zero levels in 2024 Q2; the latest four quarters average $5.21 above drug cost — the full report shows the break. |
| Idaho | FFS only | $9.41 | — | — | — | Idaho Medicaid pays pharmacies only through fee-for-service, so the FFS column is the whole story: pharmacies averaged $9.41 profit per generic prescription over the drug's cost (before wages and overhead). |
| Illinoisfull report | 94% MCO 6% FFS | $6.02 | $5.93 | $8.85 | −$2.92 | Plans reported paying pharmacies $5.93 per generic prescription above drug cost — enough that the reported payments must include a dispensing fee, not just the drug (against the $8.85 dispensing fee the state publishes). |
| Indianafull report | 90% MCO 10% FFS | $9.08 | $8.51 | $10.48 | −$1.97 | Plans reported paying pharmacies $8.51 per generic prescription above drug cost — enough that the reported payments must include a dispensing fee, not just the drug (against the $10.48 dispensing fee the state publishes). |
| Kansasfull report | 100% MCO 0% FFS | — | $11.60 | $10.50 | +$1.10 | Plans reported paying pharmacies $11.60 per generic prescription above drug cost — enough that the reported payments must include a dispensing fee, not just the drug (against the $10.50 dispensing fee the state publishes). |
| Kentuckyfull report | 95% MCO 5% FFS | — | $8.57 | $10.64 | — | The filings jumped between fee-included and near-zero levels in 2024 Q1; the latest four quarters average $8.57 above drug cost — the full report shows the break. |
| Louisianafull report | 96% MCO 4% FFS | — | $7.91 | $11.81 | −$3.90 | Plans reported paying pharmacies $7.91 per generic prescription above drug cost — enough that the reported payments must include a dispensing fee, not just the drug (against the $11.81 dispensing fee the state publishes). |
| Massachusettsfull report | 67% MCO 33% FFS | $8.87 | $11.31 | $10.02 | +$1.29 | Plans reported paying pharmacies $11.31 per generic prescription above drug cost — enough that the reported payments must include a dispensing fee, not just the drug (against the $10.02 dispensing fee the state publishes). |
| Marylandfull report | 63% MCO 37% FFS | $10.86 | $1.62 | $10.67 | — | Plans reported paying just $1.62 above drug cost — essentially the drug alone; the $10.67 dispensing fee the state publishes is nowhere in these filings. Most likely the plans do pay a dispensing fee that simply goes unreported in CMS's State Drug Utilization Data — in Oklahoma, the one state where this was ground-truthed, pharmacists confirmed exactly that. |
| Maine | FFS only | $8.94 | — | — | — | Maine Medicaid pays pharmacies only through fee-for-service, so the FFS column is the whole story: pharmacies averaged $8.94 profit per generic prescription over the drug's cost (before wages and overhead). |
| Michiganfull report | 67% MCO 33% FFS | $9.78 | $1.59 | $10.64 | — | Plans reported paying just $1.59 above drug cost — essentially the drug alone; the $10.64 dispensing fee the state publishes is nowhere in these filings. Most likely the plans do pay a dispensing fee that simply goes unreported in CMS's State Drug Utilization Data — in Oklahoma, the one state where this was ground-truthed, pharmacists confirmed exactly that. |
| Minnesotafull report | 85% MCO 15% FFS | $25.44† | $11.07 | $10.77 | +$0.30 | Plans reported paying pharmacies $11.07 per generic prescription above drug cost — enough that the reported payments must include a dispensing fee, not just the drug (against the $10.77 dispensing fee the state publishes). |
| Missouri | FFS only | $11.11 | — | — | — | Missouri Medicaid pays pharmacies only through fee-for-service, so the FFS column is the whole story: pharmacies averaged $11.11 profit per generic prescription over the drug's cost (before wages and overhead). |
| Mississippifull report | 84% MCO 16% FFS | $7.41 | $11.30 | $11.29 | +$0.01 | Plans reported paying pharmacies $11.30 per generic prescription above drug cost — enough that the reported payments must include a dispensing fee, not just the drug (against the $11.29 dispensing fee the state publishes). |
| Montana | FFS only | $11.51 | — | — | — | Montana Medicaid pays pharmacies only through fee-for-service, so the FFS column is the whole story: pharmacies averaged $11.51 profit per generic prescription over the drug's cost (before wages and overhead). |
| North Carolinafull report | 94% MCO 6% FFS | $8.75 | $10.96 | $10.24 | +$0.72 | Plans reported paying pharmacies $10.96 per generic prescription above drug cost — enough that the reported payments must include a dispensing fee, not just the drug (against the $10.24 dispensing fee the state publishes). |
| North Dakota | Mostly FFS | $10.69 | — | — | — | North Dakota pays pharmacies through fee-for-service for nearly everyone; only its small Medicaid Expansion population runs through a managed-care plan. The few managed-care rows left in the file are residue, so no margin is shown or judged. |
| Nebraskafull report | 100% MCO 0% FFS | — | $7.22 | $10.38 | −$3.16 | Plans reported paying pharmacies $7.22 per generic prescription above drug cost — enough that the reported payments must include a dispensing fee, not just the drug (against the $10.38 dispensing fee the state publishes). |
| New Hampshirefull report | 100% MCO 0% FFS | — | $2.25 | $10.47 | — | Plans reported $2.25 above drug cost — more than nothing, but well short of the $10.47 dispensing fee the state publishes; we don't call it either way. |
| New Jerseyfull report | 99% MCO 1% FFS | — | $3.91 | $10.92 | — | Plans reported $3.91 above drug cost — more than nothing, but well short of the $10.92 dispensing fee the state publishes; we don't call it either way. |
| New Mexicofull report | 97% MCO 3% FFS | — | $11.18 | $10.30 | +$0.88 | Plans reported paying pharmacies $11.18 per generic prescription above drug cost — enough that the reported payments must include a dispensing fee, not just the drug (against the $10.30 dispensing fee the state publishes). |
| Nevadafull report | 72% MCO 28% FFS | $8.01 | $4.14 | $10.17 | — | The filings jumped between fee-included and near-zero levels in 2023 Q3; the latest four quarters average $4.14 above drug cost — the full report shows the break. |
| New Yorkfull report | Carve-out: drugs paid FFS | $10.39 | — | $10.18 | — | NYRx: on April 1, 2023, New York moved the pharmacy benefit for all mainstream managed-care members back to the state, which now pays pharmacies directly. The few managed-care rows left in the file are residue, so no margin is shown or judged. |
| Ohiofull report | 90% MCO 10% FFS | $8.97 | $8.97 | $8.92 | +$0.05 | Plans reported paying pharmacies $8.97 per generic prescription above drug cost — enough that the reported payments must include a dispensing fee, not just the drug (against the $8.92 dispensing fee the state publishes). |
| Oklahomafull report | 60% MCO 40% FFS | $10.16 | $0.47 | $11.41 | — | The filings jumped between fee-included and near-zero levels in 2024 Q3; the latest four quarters average $0.47 above drug cost — the full report shows the break. Most likely the dispensing fee is still paid and simply goes unreported — that is what pharmacists confirmed in Oklahoma. |
| Oregonfull report | 73% MCO 27% FFS | $9.18 | $4.76 | $9.80 | — | Plans reported $4.76 above drug cost — more than nothing, but well short of the $9.80 dispensing fee the state publishes; we don't call it either way. |
| Pennsylvaniafull report | 99% MCO 1% FFS | — | $7.08 | $10.00 | −$2.92 | Plans reported paying pharmacies $7.08 per generic prescription above drug cost — enough that the reported payments must include a dispensing fee, not just the drug (against the $10.00 dispensing fee the state publishes). |
| Puerto Rico | 100% MCO 0% FFS | — | $4.92 | — | — | Plans reported $4.92 above drug cost — more than nothing, but well short of a typical published dispensing fee of $8–12; we don't call it either way. |
| Rhode Islandfull report | 97% MCO 3% FFS | — | $5.02 | $8.96 | −$3.94 | Plans reported paying pharmacies $5.02 per generic prescription above drug cost — enough that the reported payments must include a dispensing fee, not just the drug (against the $8.96 dispensing fee the state publishes). |
| South Carolinafull report | 86% MCO 14% FFS | $10.89 | $5.48 | $10.50 | −$5.02 | Plans reported paying pharmacies $5.48 per generic prescription above drug cost — enough that the reported payments must include a dispensing fee, not just the drug (against the $10.50 dispensing fee the state publishes). |
| South Dakota | FFS only | $37.45† | — | — | — | South Dakota Medicaid pays pharmacies only through fee-for-service, but its $37.45 average is not typical pharmacy profit — it is inflated by Indian Health Service and Tribal pharmacies, which are paid one flat rate per patient visit, hundreds of dollars regardless of the drug. |
| Tennesseefull report | Carve-out: drugs paid FFS | $8.85 | — | $9.02 | — | TennCare's single PBM: since January 1, 2020, one state-contracted PBM (Optum Rx) has processed every TennCare pharmacy claim at the state's published formula, outside the managed-care plans' own PBM arrangements. The few managed-care rows left in the file are residue, so no margin is shown or judged. |
| Texasfull report | 99% MCO 1% FFS | — | $1.67 | $8.09 | — | Plans reported paying just $1.67 above drug cost — essentially the drug alone; the $8.09 dispensing fee the state publishes is nowhere in these filings. Most likely the plans do pay a dispensing fee that simply goes unreported in CMS's State Drug Utilization Data — in Oklahoma, the one state where this was ground-truthed, pharmacists confirmed exactly that. |
| Utahfull report | 55% MCO 45% FFS | $12.51 | $3.92 | $11.56 | — | The filings jumped between fee-included and near-zero levels in 2026 Q1; the latest four quarters average $3.92 above drug cost — the full report shows the break. |
| Virginiafull report | 99% MCO 1% FFS | — | $7.99 | $10.65 | −$2.66 | Plans reported paying pharmacies $7.99 per generic prescription above drug cost — enough that the reported payments must include a dispensing fee, not just the drug (against the $10.65 dispensing fee the state publishes). |
| Vermont | FFS only | $8.44 | — | — | — | Vermont Medicaid pays pharmacies only through fee-for-service, so the FFS column is the whole story: pharmacies averaged $8.44 profit per generic prescription over the drug's cost (before wages and overhead). |
| Washingtonfull report | 96% MCO 4% FFS | — | $5.32 | $9.80 | — | The filings jumped between fee-included and near-zero levels in 2024 Q3; the latest four quarters average $5.32 above drug cost — the full report shows the break. |
| Wisconsin | FFS only | $11.20 | — | — | — | Wisconsin Medicaid pays pharmacies only through fee-for-service, so the FFS column is the whole story: pharmacies averaged $11.20 profit per generic prescription over the drug's cost (before wages and overhead). |
| West Virginia | Carve-out: drugs paid FFS | $8.45 | — | — | — | West Virginia pulled the pharmacy benefit out of its managed-care plans in July 2017 and has paid pharmacies directly ever since — the state acts as its own PBM, a move it credits with saving $54 million in the first year. The few managed-care rows left in the file are residue, so no margin is shown or judged. |
| Wyoming | FFS only | $9.32 | — | — | — | Wyoming Medicaid pays pharmacies only through fee-for-service, so the FFS column is the whole story: pharmacies averaged $9.32 profit per generic prescription over the drug's cost (before wages and overhead). |
† and — explained in “How to read this honestly,” just below.
How to read this honestly
- A “fee missing” verdict is evidence about the filing, not proof pharmacies went unpaid — in Oklahoma, pharmacists confirmed the dispensing fee is paid but absent from the file. Each state deserves its own ground-truthing before stronger claims; that is what the per-state deep reports are for.
- Margins can also be depressed by state-specific ingredient pricing (MAC lists below NADAC) or inflated by supplemental payments — the bands are deliberately wide and the middle is labeled “unclear.”
- Fee-for-service margins near typical professional dispensing fees across most states are the internal control: the methodology recovers the dispensing fee where it is known to be included.
- † FFS margins far above any published dispensing fee are not dispensing fees at all. New Mexico's ~$440/prescription is Indian Health Service billing: since 2021 the state pays IHS and Tribal 638 pharmacies a flat all-inclusive rate (set federally, roughly $500–800) per claim regardless of the drug — in the drug-level data, a quarter's ibuprofen and semaglutide fills both reimburse near $800. Native American members can opt out of managed care, so these claims concentrate in the small FFS residual. Washington, Arizona, South Dakota, and Minnesota show milder versions of the same effect, and Louisiana's inflation is different in kind: clinic-administered injectables billed through its small FFS file at facility rates. Where such a number still appears it carries the † — read it as clinic funding passing through the pharmacy file, not pharmacy profit; the most extreme cases sit in states whose FFS remnant is under 5% of prescriptions, and those cells are dashed out of the table entirely.
- A “—” in a margin column is deliberate. In the MCO column: carve-out states (California, New York, Tennessee, West Virginia) and FFS-only states pay pharmacies outside managed care, so their few leftover managed-care rows are residue — averaged, they produce nonsense (California's residue reads ~$50, New York's ~$117, Vermont's goes negative). In the FFS column: when fee-for-service holds under 5% of a state's prescriptions, its average is a tiny-remnant artifact — Texas's remnant reads negative, New Mexico's reads ~$440 (the IHS billing described above). In both cases we print a dash rather than a number that would mislead.
The audit record: what states found when they looked
This survey measures filings; several states went further and audited the actual money. Every time one looked, the gap between what plans paid PBMs and what PBMs paid pharmacies turned out to be real. The official documents:
- Ohio, 2018. The Auditor of State's Ohio's Medicaid Managed Care Pharmacy Services found PBMs charged the managed-care plans $224.8 million more than they paid pharmacies over one year (April 2017 – March 2018) — an 8.9% spread overall, and 31.4% on generic drugs. Ohio scrapped spread pricing before the report was even public and later moved every claim to a single pass-through PBM — which is why Ohio serves as this survey's positive control.
- Kentucky, 2019. The Cabinet for Health and Family Services' Medicaid Pharmacy Pricing: Opening the Black Box found two PBMs kept $123.5 million in spread from Kentucky Medicaid in 2018 alone. Kentucky moved all managed-care pharmacy claims to a single state-contracted PBM in 2021.
- Pennsylvania, 2024. The Auditor General's audit of PBM services in the HealthChoices program found the state failed to effectively monitor $4.6 billion in annual pharmacy spending, and that undisclosed spread pricing and transmission fees PBMs never reported to the plans or the state cost taxpayers roughly $7 million in 2022 alone.
- Maryland, 2018 and 2023. Two Department of Health reports to the legislature — the 2018 PBM Joint Chairmen's Report and the 2023 report on MCO prescription drug claims — found all nine HealthChoice MCOs run pharmacy through PBMs paying dispensing fees well below the $10.67 fee-for-service fee. Maryland is the state where the shortfall in this table is best documented as genuinely lower payment, not just missing reporting.
- Florida, 2020–2021 (commissioned analysis, not a state audit): Sunshine in the Black Box (3 Axis Advisors, for the Florida Pharmacy Association) examined 359 million Florida Medicaid claims from 2012–2019 and documented PBMs steering claims to their own affiliated pharmacies at premium prices while dozens of small pharmacies averaged below-cost reimbursement. The legislature's 2021 House subcommittee review of PBM pricing practices followed.
A DrugDashboards report · the Oklahoma deep report · site-wide methodology · informational only — not legal, clinical, or purchasing advice.