How to keep your prescriptions affordable

Who this guide is for

You take one or more prescription medications and want to understand your options for keeping the cost manageable. Maybe you have insurance and aren't sure how your drug benefit works, or maybe you don't have coverage at all and are trying to figure out where to turn.

This guide starts by helping you identify which category you're in, because your options depend heavily on your insurance situation. From there, jump to the section that applies to you. If you're comparing Medicare plans generally and this is your first time enrolling, our first-time Medicare guide is a better starting point before you get into Part D specifics.

Your decision checklist

What are my prescription coverage options? (This is the central fork in this guide.)
If I have commercial or employer insurance: how does my drug benefit work?
If I have a Marketplace plan: what should I know?
If I have Medicaid: what does Medicaid cover?
If I have Medicare: what about Part D?
What if I have no prescription coverage?
Drug discount cards and programs
Mark Cuban Cost Plus Drugs
Manufacturer assistance and patient assistance programs
My action plan for lowering prescription costs

1. What are my prescription coverage options?

What you're deciding: Which section of this guide applies to your situation.

Eligibility check: Your prescription coverage options depend entirely on what insurance, if any, you currently have. There isn't a single "best" path here. The right section for you is determined by your coverage status, not by preference.

Commercial or employer insurance. If you get health insurance through a job (yours or a family member's), your plan generally includes a prescription drug benefit as part of the medical plan or through a separate pharmacy benefit manager (PBM). Go to Decision 2.
Marketplace (ACA) plan. If you bought an ACA-compliant individual plan through HealthCare.gov, your state exchange, or directly from an insurer, prescription drug coverage is included as an essential health benefit. (Short-term and some other non-ACA plans sold off-Exchange may exclude drugs.) Go to Decision 3.
Medicaid. If you qualify for Medicaid in your state, outpatient drug coverage is generally included. Note: starting no later than January 1, 2027, most non-pregnant expansion adults ages 19-64 must show 80 hours a month of work, school, or service (with exemptions) to qualify or stay enrolled. Go to Decision 4.
Medicare. If you're enrolled in Medicare, prescription coverage works differently than the options above and depends on whether you have a standalone Part D plan, a Medicare Advantage plan with drug coverage built in, or no drug coverage at all. Go to Decision 5.
No insurance, or a plan with no drug coverage. If you don't have insurance, or your coverage doesn't include prescriptions, you'll generally pay cash prices, which vary enormously by pharmacy. Go to Decision 6.

This is the central fork in this guide. Every other decision in this guide, discount programs, Cost Plus Drugs, and patient assistance, can layer on top of whichever category applies to you. Read your relevant section first, then continue to sections 7 through 9, which apply regardless of your coverage status.

Go deeper: Understanding your health insurance card and benefits

2. If I have commercial or employer insurance: how does my drug benefit work?

What you're deciding: How to use your existing drug benefit effectively and what to do if a medication isn't covered.

Eligibility check: This section applies if you have coverage through an employer plan (yours or a family member's) or a non-ACA private plan. ACA-compliant individual plans, including those bought directly from an insurer off-Exchange, are covered in Decision 3. Your specific benefit details depend on your employer's plan design and the pharmacy benefit manager (PBM) that administers it, so treat the general patterns below as a starting point, not a guarantee of what your plan does.

How formularies work

Most commercial plans organize covered drugs into a formulary, a list of medications the plan covers, generally sorted into tiers:

Tier 1: Generic drugs. Lowest copay, typically.
Tier 2: Preferred brand-name drugs. Moderate copay.
Tier 3: Non-preferred brand-name drugs. Higher copay.
Tier 4-6 (where they exist): Specialty drugs, often for complex conditions. These may require coinsurance (a percentage of the cost) rather than a flat copay, and the coinsurance on specialty tiers can be substantial.

Most plans use four to six tiers, though the exact structure varies by plan and PBM. Formularies can and do change annually, sometimes mid-year. A drug covered at a low copay this year could move to a higher tier, or off the formulary entirely, next year.

Utilization management tools

Plans may apply additional rules before covering a specific drug:

Prior authorization: Your doctor must submit documentation showing the drug is medically necessary before the plan will cover it.
Step therapy: You may be required to try a lower-cost drug first and show it doesn't work before the plan covers a more expensive one.
Quantity limits: The plan may cap how much of a drug it covers per fill or per month.

Checking whether your drug is covered

Check your plan's formulary, generally available through your insurer's website or member portal, before assuming a medication is covered at a particular cost. Formularies are searchable by drug name and typically show the tier and any utilization management requirements.

If your drug isn't covered

Ask your doctor about a formulary alternative. Often a similar drug in the same class is covered at a lower tier.
File a formulary exception request. Your doctor can request coverage for a non-formulary drug when there's a medical reason a covered alternative won't work. This process and its required documentation vary by plan.
Appeal a denial. If a prior authorization or exception request is denied, you generally have the right to appeal, both through an internal review with the insurer and, if that fails, an external review by an independent third party.

Mail-order pharmacy

Many commercial plans offer a mail-order option for maintenance medications (drugs you take regularly, like those for blood pressure or cholesterol), often at a lower per-fill cost for a 90-day supply compared to three separate 30-day fills at a retail pharmacy. Check whether your plan offers this and whether your specific medications qualify.

Go deeper: How prior authorization works · How to appeal a coverage denial

3. If I have a Marketplace plan: what should I know?

What you're deciding: How to evaluate a Marketplace plan's drug coverage, either during enrollment or to understand the plan you already have.

Eligibility check: This section applies to anyone enrolled in an ACA-compliant individual plan, whether purchased on-Exchange through the Marketplace or off-Exchange directly from an insurer. All ACA-compliant plans are required to cover prescription drugs as one of the essential health benefits, so coverage itself isn't in question. What varies is which specific drugs are covered, at what cost, and under what conditions.

Formularies vary dramatically between plans

Two Marketplace plans in the same metal tier, sold in the same area, can have meaningfully different formularies. One may cover your medication at a low copay; another may place the same drug on a higher tier or require prior authorization. If you take a specific medication regularly, check the formulary of any plan you're considering before enrolling, not after. ACA-compliant plans that provide essential health benefits must publish an up-to-date, accurate, and complete drug list, viewable on the plan's public website without needing an account or policy number.

Metal tier and drug costs

Higher metal tiers (Gold, Platinum where available) generally come with lower drug copays and coinsurance, in exchange for a higher monthly premium. Lower metal tiers (Bronze) generally have higher drug cost-sharing paired with a lower premium. Whether a higher tier is worth it depends on how many medications you take regularly and their cost at each tier, not just the premium difference.

Generic vs. brand-name

This distinction matters significantly for what you'll pay:

Generic drugs are typically the lowest-cost tier on nearly every Marketplace formulary.
Brand-name drugs, especially when a generic equivalent exists, are typically priced much higher out of pocket, and some plans may not cover the brand-name version at all if a generic alternative is available, unless your doctor documents a medical reason.
If you currently take a brand-name drug, ask your doctor whether a generic equivalent is appropriate for you. This can meaningfully lower your out-of-pocket cost regardless of which plan you choose.

What to check before enrolling

Look up each of your current medications in the formulary of any plan you're considering.
Note the tier, any prior authorization or step therapy requirements, and the estimated copay or coinsurance.
If you take a specialty medication, check the specialty tier cost-sharing specifically. This can be a meaningful factor in total annual cost, sometimes more significant than the premium difference between plans.

Go deeper: Metal tiers explained · How to check a plan's formulary before enrolling

4. If I have Medicaid: what does Medicaid cover?

What you're deciding: What to expect from Medicaid's prescription drug coverage and where cost-sharing may apply.

Eligibility check: This section applies if you're enrolled in Medicaid. Medicaid eligibility itself depends on income, household size, age, disability, pregnancy, and other factors, plus whether your state has expanded Medicaid under the ACA. Starting by January 1, 2027, most non-pregnant expansion adults ages 19-64 also must show 80 hours a month of work, school, or service (with exemptions). Eligibility, income thresholds, and program rules vary by state, so confirm your specific state's rules rather than assuming national figures apply to you.

Coverage is generally comprehensive

Medicaid prescription drug coverage varies by state, since each state administers its own Medicaid program within federal guidelines, but every state covers outpatient prescription drugs, and coverage is generally broad. (Eligibility for Medicaid itself may now include work requirements; see the eligibility check above.) Every state provides that coverage through the Medicaid Drug Rebate Program, in which participating drug manufacturers pay rebates that offset federal and state costs. Most outpatient drugs from participating manufacturers are covered, though states can use preferred drug lists and prior authorization.

Medicaid prescription copays are typically small (often $1 to $4 for preferred or generic drugs), but states can charge more: federal rules allow roughly $4 for preferred drugs, up to about $8 (indexed for inflation) for non-preferred drugs, and 20% of the state's cost for non-preferred drugs for people above 150% of the federal poverty level. Children, pregnant women, and certain others cannot be charged, and total household cost-sharing is capped at 5% of income. Check your specific state's Medicaid cost-sharing schedule, since it may differ from these general figures.

Preferred drug lists

Many states maintain a preferred drug list (PDL), similar in concept to a formulary, that lists which drugs are covered without additional steps and which require prior authorization. If your medication isn't on the preferred list, your doctor may need to request an exception or try a preferred alternative first.

Expansion vs. non-expansion states

States that expanded Medicaid under the ACA may have slightly different formulary structures or managed care arrangements than non-expansion states, since expansion states often deliver Medicaid benefits through managed care organizations that maintain their own formularies within state guidelines. If you're unsure whether your state expanded Medicaid or how your specific plan's formulary works, your state Medicaid office or your managed care plan's member services line can clarify.

Go deeper: How Medicaid eligibility works · Medicaid managed care explained

5. If I have Medicare: what about Part D?

What you're deciding: Whether you need a Part D plan and how it generally works. This section is a summary; the full walkthrough lives elsewhere.

Eligibility check: This section applies if you're enrolled in Medicare, whether Original Medicare or a Medicare Advantage plan. Part D eligibility generally follows Medicare eligibility: you're eligible to enroll in a Part D plan once you're eligible for Medicare Part A or enrolled in Part B.

The basics

Part D covers outpatient prescription drugs and is available two ways:

A standalone Part D plan, purchased alongside Original Medicare (Parts A and B).
Built into a Medicare Advantage plan that includes drug coverage (often labeled MA-PD).

The Part D cost structure

Part D has a distinct cost structure that unfolds across the year: a deductible (if your plan has one), an initial coverage phase, and catastrophic coverage once you reach the annual out-of-pocket cap. The old "coverage gap" (donut hole) phase was eliminated by the Part D redesign that took effect in 2025. How much you pay depends on your specific plan and your total drug spending for the year.

The annual out-of-pocket cap ($2,100 in 2026, $2,400 in 2027) is a significant consumer protection: once your out-of-pocket spending on covered drugs reaches this cap, you pay nothing more for covered drugs for the rest of the plan year. The cap is indexed annually ($2,000 when it took effect in 2025).

The late enrollment penalty

If you go 63 days or more in a row without Part D or other creditable prescription drug coverage after your Initial Enrollment Period ends, you may owe a late enrollment penalty: 1% of the national base beneficiary premium for each full uncovered month, added to your monthly Part D premium for as long as you have Part D coverage. This makes the enrollment timing decision more consequential than it might first appear, even for people who don't take many medications currently.

This guide does not walk through how to choose a Part D plan in detail. For the full walkthrough, including how to compare plans, estimate your annual cost, and understand the enrollment timeline, see our Part D section. If this is your first time navigating Medicare generally, start with our first-time Medicare guide for broader context before narrowing into Part D specifics.

Go deeper: Choosing a Part D plan · Medicare: first-time enrollment guide · The Part D late enrollment penalty

6. What if I have no prescription coverage?

What you're deciding: How to find the lowest available price for your medications when you're paying entirely out of pocket.

Eligibility check: This section applies if you have no health insurance, or your current insurance doesn't include prescription drug coverage. It applies regardless of why: between jobs, a plan that excludes drug benefits, or a gap in coverage.

Cash prices vary enormously

The price of the same medication at the same dose can differ by an enormous margin between pharmacies, sometimes the difference between $15 and $300 for an identical prescription, depending on the pharmacy, your location, and which pricing or discount arrangement applies. Cash pricing is generally not standardized and can change without notice, which means the pharmacy you'd naturally choose (the one closest to you, or the one you've always used) is not necessarily the least expensive option.

How to compare prices

Use a price comparison tool such as GoodRx, RxSaver, or a similar service before filling a prescription. These tools show estimated cash prices at nearby pharmacies for your specific medication and dose.
Ask the pharmacy directly for their cash price, even if you have insurance. In some cases, particularly with high-deductible plans, the cash price is lower than what you'd pay toward your deductible through insurance.
Consider mail-order and online pharmacies. Some online pharmacies offer lower prices than local retail pharmacies for certain medications, particularly for maintenance drugs taken regularly.

The active-comparison reality

Price transparency in prescription drugs has improved with the growth of comparison tools, but it still generally requires you to actively compare rather than assume any single pharmacy has the best price. This is an ongoing task, not a one-time check, since prices can shift.

Go deeper: How to compare prescription prices across pharmacies

7. Drug discount cards and programs

What you're deciding: Whether a discount program could lower your cost, whether or not you have insurance.

Eligibility check: Discount programs like GoodRx, RxSaver, SingleCare, and pharmacy-specific programs such as Amazon Pharmacy are generally available to anyone, free to sign up for, and don't require enrollment through an insurer or employer. They are not insurance.

How they work

These programs negotiate discounted rates with pharmacies and networks of pharmacy benefit managers, then pass a version of that discount to you when you present the card or code (often through an app) at checkout. There's typically no cost to use them and no eligibility requirement beyond having a prescription to fill.

Typical savings and limitations

Savings vary by drug, pharmacy, and location. Some medications see substantial discounts; others see little to no difference from the standard cash price.
Not all drugs are included, and not all pharmacies participate in every discount network.
Prices shown in these apps can fluctuate and aren't guaranteed until you're at the pharmacy counter.
These programs generally cannot be combined with insurance for the same fill. You choose one or the other for a given prescription.

When the discount price beats your insurance copay

If you have insurance, it can still be worth comparing the discount card price to your insurance copay before each fill, particularly for generic medications. In some cases, the discount price is lower than your copay would be, in which case you may choose to pay cash using the discount rather than run the fill through insurance. Understand that a fill paid this way generally won't count toward your insurance deductible or out-of-pocket maximum, so weigh that tradeoff against the immediate savings.

Manufacturer coupons

Separately from discount cards, drug manufacturers sometimes offer coupons for brand-name drugs, which can reduce your out-of-pocket cost if you're prescribed that specific brand. These are generally not available if you're covered by a federal health program such as Medicare, Medicaid, or TRICARE, because the federal anti-kickback statute applies; coupon terms typically exclude these beneficiaries. Check the coupon's terms before assuming it applies to you.

Go deeper: How drug discount cards work · Discount card vs. insurance copay: which is cheaper?

8. Mark Cuban Cost Plus Drugs

What you're deciding: Whether this specific pharmacy model could lower your cost for a particular medication.

Eligibility check: Cost Plus Drugs is available to any consumer in states where it operates, regardless of insurance status. It does not require enrollment in a health plan, and there's no application or eligibility screening beyond having a valid prescription for a medication it carries.

What it is

Cost Plus Drugs is an online, mail-order pharmacy that prices medications based on the manufacturer's cost, plus a fixed markup (publicly stated as roughly 15%), plus a pharmacy and shipping fee. This pricing model is different from typical retail pharmacy pricing, which can involve multiple intermediaries and less transparent markups.

How it works

You order through their website with a valid prescription, which can often be transferred electronically from your current pharmacy or sent by your doctor.
Medications are shipped by mail, generally within a few days, rather than picked up in person.
The company reports carrying several thousand medications, though the specific list changes over time and doesn't include every drug on the market.

What it doesn't do

It does not accept insurance. You pay the listed cash price directly; there is no mechanism to apply this toward an insurance deductible or copay.
It is mail-order only. There's no option for same-day, in-person pickup, which matters if you need a medication urgently.
Not every medication is available. Certain controlled substances, specialty drugs requiring special handling, and drugs outside their current catalog may not be carried.
Availability can vary by state due to pharmacy licensing requirements. Confirm it operates in your state before assuming it's an option.

When it may make sense

This option is generally most relevant for expensive brand-name or specialty medications that aren't well covered by your insurance, or for consumers without drug coverage who take a maintenance medication regularly and can plan ahead for mail delivery rather than needing an immediate fill. For inexpensive generics you already get cheaply through a discount card or insurance copay, the practical difference may be minimal.

Go deeper: Mail-order pharmacy basics · Comparing cash-pay pharmacy options

9. Manufacturer assistance and patient assistance programs

What you're deciding: Whether you qualify for help that many consumers who are eligible never claim.

Eligibility check: Eligibility varies by program. Some are open to anyone with commercial insurance who's prescribed a specific brand-name drug; others are income-based and intended for people who are uninsured or underinsured. Check the specific program tied to your medication, since terms differ drug by drug and company by company.

Manufacturer copay assistance cards

Many drug manufacturers offer copay assistance cards for their brand-name products, intended for people with commercial insurance who are prescribed that drug. These can reduce your out-of-pocket copay substantially. They are generally not available if you have Medicare, Medicaid, TRICARE, or another federal health program, because of the federal anti-kickback statute. Separate manufacturer patient assistance programs may still help some people with Medicare; check each program's rules.

Patient assistance programs (PAPs)

Separately, many manufacturers run patient assistance programs aimed at people who are uninsured or underinsured, generally based on income. These programs may provide the medication at no cost or steeply reduced cost directly from the manufacturer. Income thresholds and application requirements vary by program and by drug.

Directories to find these programs

NeedyMeds and RxAssist are commonly referenced directories that compile manufacturer assistance programs, searchable by drug name.
Your prescribing doctor's office or the pharmacy filling your prescription may also know whether assistance exists for a specific medication, since these programs are often drug-specific rather than universal.

340B program

Some qualifying health centers, generally those serving low-income or underserved populations, participate in the 340B drug pricing program, which allows them to purchase certain outpatient drugs at reduced cost and, in some cases, pass savings to patients. Availability depends on whether you receive care at a participating 340B facility.

State pharmaceutical assistance programs (SPAPs)

Some states run their own assistance programs, generally aimed at specific populations such as older adults or people with particular conditions, that supplement other coverage. Availability and eligibility rules are state-specific.

Why this section matters

These programs are widely underused. Many people who would qualify, particularly for income-based patient assistance programs, are unaware they exist or assume they wouldn't qualify without checking. If you're struggling with the cost of a specific medication, checking whether a manufacturer or patient assistance program applies is generally worth the time before assuming there's no help available.

Go deeper: How manufacturer copay cards work · Finding a patient assistance program for your medication

Your action plan for lowering prescription costs

First: confirm your coverage category

Identify which category applies to you: commercial/employer insurance, Marketplace plan, Medicaid, Medicare, or no coverage. Go to the matching section above.
Check your plan's formulary (if you have one) for each medication you currently take, and note the tier, copay, and any prior authorization or step therapy requirements.

For everyone, regardless of coverage

Ask your doctor about generic alternatives for any brand-name drug you're prescribed, where a generic equivalent exists.
Compare cash prices using a discount tool like GoodRx or RxSaver, even if you have insurance, particularly for generics.
Check whether Cost Plus Drugs carries your medication if you take an expensive brand-name or specialty drug without strong insurance coverage for it.
Search a patient assistance directory such as NeedyMeds or RxAssist for any medication that remains expensive after the steps above.
Ask your pharmacist directly whether a lower-cost option exists for your specific prescription. Pharmacists often know about discounts, generic swaps, and assistance programs that aren't obvious from your insurance paperwork alone.

If you have Medicare and haven't reviewed Part D recently

Confirm you have creditable drug coverage to avoid the late enrollment penalty, if you're newly eligible for Medicare.
Review your Part D or Medicare Advantage drug coverage annually, since formularies and costs can change each plan year. See our Part D section for the full comparison process.

When to get help

Some prescription cost questions are simple. Others involve interacting coverage rules, formulary exceptions, and assistance program eligibility that are genuinely complex.

Consider personalized guidance if:

A medication you need isn't covered by your plan and you're unsure whether to pursue an exception, an appeal, or a formulary alternative.
You're choosing a Marketplace or Medicare plan and want to compare formularies for your specific medications before enrolling.
You think you might qualify for a patient assistance program but aren't sure how to apply or what documentation is required.
You're managing multiple medications across different cost-saving strategies and want to make sure you're not missing a lower-cost option.

For plan selection and formulary comparison: A licensed agent or broker can help you compare plan formularies against your specific medications at no additional cost to you. Healthcare.com's licensed agents can walk through your options.

For coverage denials and appeals: Your plan's member services line can explain the appeals process, and in some cases a patient advocate or your doctor's office can assist with documentation.

For assistance program applications: The manufacturer's patient assistance program contact, or directories like NeedyMeds, can clarify eligibility and application steps for a specific medication.

This guide provides general educational information, not medical, legal, or financial advice. Prescription drug coverage, formularies, cost-sharing, and program availability depend on individual circumstances, your specific plan, your state, and the current plan year, and may change. Consult a licensed agent, your insurer, your pharmacist, or a qualified professional for advice specific to your situation.