Key takeaways:
Most health insurance plans, including Medicaid and Medicare policies, cover prescription medications. However, the specific medications covered can vary widely by plan.
To check if a medication is covered through your plan, review your plan’s formulary, call your insurer, or ask your pharmacist to run a coverage check.
If your medication isn’t covered, request a formulary exception or ask your prescriber about alternatives. You can also use a GoodRx coupon or check for patient assistance programs.
If you’ve been prescribed a new medication, your first thought might be: Will my insurance cover it? You might also wonder whether you’ll be able to fill the prescription if the cost is too high.
Most health insurance plans cover prescription medications, but the specifics vary from plan to plan. Don’t wait until you get to the pharmacy counter to find out if your medication is covered. There are ways to check coverage in advance to save time and avoid surprises.
Does health insurance cover prescriptions?
Most health insurance plans, including those offered through the Affordable Care Act (ACA), cover prescription medications. But each plan decides what medications it will pay for. GoodRx research shows that about 1 in 5 medications aren’t covered by the average commercial insurance plan.
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Insurance plans may only cover medications listed on their formulary. Some insurers cover a wider range of medications, but often with restrictions, such as prior authorization or step therapy requirements, which we cover below. In fact, more than one-third of covered medications under commercial plans come with restrictions, according to GoodRx data.
Medicare and Medicaid also offer prescription benefits. With Medicare, prescription medication coverage is typically included in a separate Part D plan. Though, Part B covers some medications and vaccines. And some Medicare beneficiaries get their medications covered through a Medicare Advantage, or Part C, plan.
Medicaid prescription medication benefits depend on the state. But plans often cover most medications.
How can you check if your insurance covers a medication?
Before filling a prescription, it’s helpful to check if your insurance covers the medication and what you might pay. You can log into your insurer’s website or app and search for your medication in your plan’s formulary. If you need additional support, call the number on your insurance card for help. A pharmacist can also check your coverage and suggest lower-cost options if needed.
Whether you’re enrolled in Medicaid, Medicare, or VA health benefits, have employer-sponsored coverage, or purchased a plan through HealthCare.gov, here’s how to check your prescription medication coverage.
Medicaid
Medicaid coverage varies by state. But states typically maintain a preferred drug list (PDL) online to help members understand which medications are covered. States typically update their PDL at the beginning of the year, but some also update at midyear based on new medication approvals or clinical guideline changes.
If your insurance denied you coverage for a prescription medication, you’re not out of options. Here are some steps to take to get help.
Looking to reduce your pharmacy bills? These strategies can help you save money on your medications.
Not all medications are covered the same way by your insurance. Read how your plan’s medication formulary can affect your out-of-pocket costs.
Many brand-name medications offer savings programs you might not know about. Find out how manufacturer copay savings cards can reduce your costs.
Here’s how to check if your Medicaid plan covers your medication:
Visit your state’s Medicaid website. If you are unable to find your state’s website, contact your state’s Medicaid office for details. You can go to www.medicaid.gov to learn more about applying for coverage.
Search for “Preferred Drug List” or “Formulary.” If you have a Medicaid managed care plan, look for your specific plan’s name.
Look up your medication by name. Some states provide searchable online tools. Others, like Florida, have their PDLs as downloadable files.
Check how your medication is listed on the PDL. Preferred medications are usually easier to get and cost less. Nonpreferred medications may require prior authorization before they are covered. For example, Ozempic (semaglutide) could be listed as “preferred” or “nonpreferred” depending on your state’s coverage.
See if there are any limits or rules. There may be extra steps you need to take to get coverage or restrictions on how much you can get at one time.
Medicare (Part D or Advantage plans)
If you have a Medicare Part D plan or a Medicare Advantage plan with prescription coverage, here’s how to check if your medication is covered:
Visit your plan’s website or app, and log into your member portal. This helps ensure your search results are based on your specific plan and coverage details.
If you don’t have an account set up, some plan websites let you search by ZIP code. Be sure to select the correct plan. You can find your plan name or code on your insurance card.
Use your plan’s searchable tool to enter the name of your medication and your prescribed dose and quantity.
Review the results to see if your medication is covered and what tier it falls under. (Lower tiers usually mean lower costs.) Note any requirements or restrictions, like quantity limits.
Some plans also show estimated out-of-pocket costs based on your selected medication.
If you’re not currently enrolled in a Medicare prescription plan, or you’re looking to change plans and want to verify that your medication is covered, try the following:
Go to Medicare.gov’s plan finder.
Log into your Medicare account or create one. You can also search by ZIP code to compare plans in your area without logging in.
Choose the type of plan you’re interested in, like a Part D plan or a Medicare Advantage plan with prescription coverage.
Enter all of your prescribed medications and doses and your preferred pharmacy information.
Review the list of plans and how each one covers your medications.
Check what tier the medications fall under and your estimated costs. Also note each plan’s monthly premiums and deductible, as these also affect your total out-of-pocket costs.
Health insurance plans often group medications into different tiers, which affects how much you’ll pay. Lower tiers (like Tier 1) usually include generic and other lower-cost medications. Higher tiers (like Tier 3 or Tier 4) often include nonpreferred brand-name or specialty medications. These medications generally cost more.
For example, Eliquis (apixaban), a medication used to treat and prevent blood clots, is typically a Tier 3 preferred brand-name medication. Some plans may charge a flat monthly copay, while others may require coinsurance, which means you’d pay a percentage of the medication’s cost.
VA health benefits
If you get your healthcare through the U.S. Department of Veterans Affairs (VA), your prescriptions are likely filled through VA pharmacies. Here’s how to check your medication coverage:
Use the VA Formulary Advisor.
Enter your medication’s name in the search field.
Select whether to filter by “VA Formulary” items only, “Urgent/Emergent Formulary” items only, or all available listings.
Review the results. The tool will tell you if the medication is on the formulary or considered nonformulary.
Note the copay tier, which determines your out-of-pocket costs.
Finally, check if prior authorization is needed. In some cases, prior authorization is managed at the local VA facility, so your prescriber may need to submit paperwork before coverage is approved.
You can also use the VA National Formulary to find out if your medication is covered:
Open the spreadsheet and search for your medication. You may need a computer to easily navigate Excel files.
Review whether it’s covered and if there are any conditions for approval.
If your medication is considered nonformulary or isn’t listed, you can ask your VA prescriber about submitting a nonformulary request. For example, Emgality (galcanezumab), a medication used to prevent migraines, is not on the VA National Formulary and requires a nonformulary request.
Employer-sponsored insurance
If you’re covered through your job, your health insurer likely provides a member portal where you can look up medications. Here’s how to check your medication coverage:
Find the name of your insurance company, along with your member ID and group number, on your card.
Go to your insurer’s website and create an account, or log in to your member portal.
Look for a section labeled “Pharmacy,” “Drug Coverage,” or “Formulary.”
In the search tool, enter your medication’s name and your prescribed dose.
Review the results to find out if your medication is covered, what tier it’s under, and if there are any requirements or restrictions. Most health plans also list the estimated copay or coinsurance amounts for medications.
If you can’t find the information you need, you can also call the number on your card or talk to your human resources representative or benefits administrator.
Marketplace insurance through HealthCare.gov
If you bought your insurance through HealthCare.gov or your state’s marketplace, here’s how to check your medication coverage:
Find your insurance company’s name and your member ID on your insurance card.
Visit your insurer’s website or app. Log into your member portal or create an account if you don’t have one.
Find the “Pharmacy,” “Prescription Benefits,” or “Formulary” section.
In the search tool, enter your medication’s name and your prescribed dose.
Review the results for your medication’s tier level and the estimated costs. Also, check if there are any requirements like prior authorization.
Check if your insurer lists similar medications with better coverage or preferred pharmacies in your network that may offer lower prices.
If you’re shopping for a new ACA plan during open enrollment or want to compare coverage before switching:
Go to the plan comparison tool on www.healthcare.gov.
Type in your ZIP code and household information to see available plans in your area.
Enter the names of your medications to see which plans cover them.
For detailed information about tier levels, prescription costs, and requirements, click on each individual plan and select “View list of covered drugs.”
What medications does insurance not usually cover?
Some types of medications are typically not covered by insurance. Others may only be covered if you meet certain criteria. These include:
Weight-loss medications: Many plans exclude medications used for chronic weight management. This includes glucagon-like peptide-1 (GLP-1) agonists like Wegovy (semaglutide) and Saxenda (liraglutide). However, weight-loss medication access may change as the Trump administration considers testing Medicaid and Medicare coverage for these medications.
Cosmetic medications: Medications used for cosmetic reasons, like finasteride (Propecia) for hair loss, are often not covered.
Fertility treatments: Prescription medications used as part of fertility treatment may not be covered.
Over-the-counter medications: Even when prescribed by a healthcare professional, many plans won’t cover medications available over the counter. This includes certain vitamins and allergy medications like loratadine (Claritin).
Brand-name medications with covered generics: If a generic version is covered, the brand-name version of a medication may not be. For instance, plans may cover generic sertraline but exclude brand-name Zoloft.
Experimental or non-FDA-approved treatments: Medications that are still under investigation, not FDA approved, or prescribed off-label may not be covered by insurance. However, if a medication is being used as part of a clinical trial, it may be provided at no cost. In these cases, the clinical trial team typically supplies the medication directly. It doesn’t go through insurance coverage.
If your medication isn’t covered, you may be able to try a covered alternative, request a formulary exception, or use savings options like GoodRx coupons to help reduce your out-of-pocket costs.
The bottom line
Most health insurance plans cover prescription medications. But some medications may be excluded due to their cost or formulary restrictions. To check if your medication is covered, review your plan’s formulary to see if it’s listed. You can also call your insurer or ask your pharmacist to run a coverage check.
Why trust our experts?
References
Florida Agency for Health Care Administration. (2025). Florida Medicaid Preferred Drug List.
HealthCare.gov (n.d.). Using your health insurance coverage.
Medicare.gov. (n.d.). Choose how you get drug coverage.
Reuters. (2025). US plans to test Medicare, Medicaid coverage for weight-loss drugs, Washington Post reports.
