Health insurance covers fewer medications than years ago

• Health insurance, including Medicare and Medicaid, is increasingly covering fewer medications or has more restrictions.
• Medicare patients are even left with less medication coverage and more restrictions compared with commercial health insurance.
• Fewer medications are being covered largely because companies that negotiate drug prices are driven to cover medications that make them the most money.

Health insurance is covering fewer medications than years ago or forcing more patients to jump through hoops.

Medicare covered 56% of medications and had restrictions, such as getting prior authorization, on 49% of medications in 2025, compared with 61% and 39% respectively in 2015, according to a report from prescription-drug website GoodRx.

Still, there is a bit of good news: Medicare covered around 2% more medications and restricted 1% fewer medications in 2025 compared with 2024.

"While the pinch let up some this year, it certainly isn’t gone," GoodRx said.

Medicare patients are often dealing with even more challenges.

Medicare didn't cover 44% of medications, compared with commercial health insurance not covering 21%, GoodRx said.

For restrictions, which are extra steps such as getting prior authorization, Medicare also fared worse with restrictions on 49% of medications, compared with 35% for commercial health insurance.

And even though Medicaid covered 97% of medications, 63% of those medications had restrictions

When a medication isn't covered or has restrictions, the first course of action is usually trying to find a cheaper alternative.

If that doesn't work, patients can try to get an exception from their health insurer, apply for a patient assistance program or find a new health plan when enrollment opens up. 

"For many Americans, the real hurdle to treatment isn’t just medication prices — it’s navigating the complex policies embedded in their health plan that dictate the cost they pay at the pharmacy counter," GoodRx said.

Why are fewer medications being covered?

Drug formularies, the list of covered medications, are largely determined by pharmacy benefit managers (PBMs), which are companies that decide drug coverage on behalf of health insurers, Medicare Part D plans, employers and other health care payers, The Lever reports.

PBMs negotiate with drug manufacturers on what health insurance will cover and how much the medications will cost, but they are incentivized to cover drugs that will make them the most money and have increasingly excluded less-profitable medications from formularies.

From 2014 to 2022, there was a 961% increase in prescription medications excluded by PBMs Express Scripts, CVS Caremark or OptumRx, according to a report from consultancy Xcenda for drug manufacturer AmerisourceBergen.

As a result, health insurance companies can change their list of covered medications throughout the year, leaving many patients unable to afford vital medications even after paying expensive insurance premiums.

“In my experience as a practicing physician, one of the greatest administrative burdens I’m facing is sudden, arbitrary changes to a patient’s medication coverage by their health plan,” Steven Furr, president of the American Academy of Family Physicians, told The Lever. “A patient can be doing well on a specific medication for years, and one day the plan no longer covers it or has a preferred alternative.”

Despite the issue, there are few regulations limiting the exclusion of medications from coverage.

“Plans can pretty much do what they please, within some broad parameters,” Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University’s McCourt School of Public Policy, told The Lever.