Understand how prescription drugs are covered across every major plan type. Live data from CMS, FDA, RxNorm, and NLM — designed for consumers, caregivers, and advocates.
Each plan type has its own formulary rules, tier structure, and cost-sharing requirements. Select your plan to explore what it means for your prescriptions.
Medicare Advantage Prescription Drug plans are offered by private insurers approved by CMS. Each plan maintains its own formulary — a list of covered drugs organized into tiers with different cost-sharing levels. Plans must cover all CMS-required "protected classes" (oncology, antiretrovirals, antipsychotics, immunosuppressants, anticonvulsants, antidepressants).
Under the Inflation Reduction Act (2025), the Part D benefit has restructured to three phases, eliminating the coverage gap ("donut hole") and capping out-of-pocket spending at $2,000/year.
| Tier | Drug Type | Typical Copay | PA Required? |
|---|---|---|---|
| Tier 1 | Preferred Generics | $0–$5 | Rarely |
| Tier 2 | Generics | $5–$20 | Sometimes |
| Tier 3 | Preferred Brand | $30–$50 | Often |
| Tier 4 | Non-Preferred Brand | $80–$120 | Usually |
| Tier 5 | Specialty | 25–33% | Required |
Part D Prescription Drug Plans work alongside Original Medicare (Parts A & B). They're sold by private insurers and must follow CMS rules. As of 2025, the IRA restructured the benefit into three clean phases: deductible, initial coverage, and catastrophic — with a hard $2,000 OOP cap on covered drugs.
PDPs must include at least two drugs per therapeutic category, and all six protected class categories must have comprehensive coverage. Formularies are filed and reviewed by CMS annually.
| Phase | 2025 Threshold | You Pay | Plan Pays |
|---|---|---|---|
| Deductible | Up to $590 | 100% | 0% |
| Initial Coverage | $590–$2,000 OOP | Copay/Coinsurance | Remainder |
| Catastrophic | After $2,000 OOP | $0 | 100% |
All Qualified Health Plans (QHPs) sold on federal and state exchanges must cover prescription drugs as an Essential Health Benefit (EHB). Plans must cover at least one drug per USP category and class. Formularies are published as machine-readable JSON files per CMS rules.
Metal tiers (Bronze, Silver, Gold, Platinum) determine cost-sharing structure, but your specific drug's formulary tier determines the actual copay or coinsurance within that metal level.
| Metal Tier | Actuarial Value | Typical Rx Cost-Share |
|---|---|---|
| 🥉 Bronze | 60% | Higher OOP; often coinsurance |
| 🥈 Silver | 70% | Moderate; CSR subsidies available |
| 🥇 Gold | 80% | Lower copays, predictable costs |
| 💎 Platinum | 90% | Lowest OOP, highest premium |
DSNPs serve individuals who qualify for both Medicare and Medicaid ("dual eligibles"). These plans coordinate benefits between both programs and typically feature $0 or very low drug cost-sharing because Medicaid covers most remaining costs.
Formulary management in DSNPs is complex — the plan must coordinate with state Medicaid PDLs (Preferred Drug Lists). Drug coverage may differ from standard MA-PD plans, and prior authorization policies tend to be more stringent for high-cost specialty drugs.
| Drug Type | LIS Copay (2025) | Non-LIS |
|---|---|---|
| Generics | $4.50 | Tier 1–2 copay |
| Brand Drugs | $11.20 | Tier 3–4 copay |
| Specialty (Institutionalized) | $0 | Tier 5 coinsurance |
| After $2,000 OOP | $0 | $0 |
TRICARE's pharmacy benefit is managed by Express Scripts under contract with the Defense Health Agency (DHA). The TRICARE formulary has three tiers: generic, formulary brand, and non-formulary brand. Active-duty members pay $0 for formulary drugs at military pharmacies (MTF).
TRICARE covers prescription drugs at Military Treatment Facilities, TRICARE Pharmacy Home Delivery, and network retail pharmacies. Non-formulary drugs require a non-formulary justification from the prescriber.
| Drug Tier | MTF | Home Delivery | Retail Network |
|---|---|---|---|
| Generic | $0 | $0 (90-day) | $14 (30-day) |
| Formulary Brand | $0 | $45 (90-day) | $38 (30-day) |
| Non-Formulary | $0 | $103 (90-day) | $84 (30-day) |
Medicaid drug coverage is governed by each state's Preferred Drug List (PDL). States receive rebates from manufacturers for including drugs on their PDLs. Coverage rules — including prior authorization, quantity limits, and step therapy — vary significantly by state and managed care organization (MCO).
Federal law requires states to cover all drugs from manufacturers who participate in the Medicaid Drug Rebate Program (MDRP), though states may impose utilization management on non-preferred drugs.
| PDL Status | Access | PA Required | Cost-Share |
|---|---|---|---|
| Preferred | Immediate | No | $0–$4 |
| Non-Preferred | Step therapy / PA | Yes | $0–$8 |
| Non-Covered | Exception only | Formulary Exception | Full cost |
Search any drug to see its FDA label data, approval status, adverse events, NDC codes, and formulary intelligence pulled live from federal APIs.
Enter a brand or generic drug name. Data is retrieved live from FDA openFDA and NLM RxNorm APIs.
Plans use these tools to manage drug spending. Understanding them helps you navigate coverage barriers and advocate for the medications you need.
A PA requires your plan to approve a drug before coverage kicks in. Plans use PA to ensure drugs are clinically appropriate and cost-effective. Under the CMS Prior Authorization Final Rule (CMS-0057-F), most MA plans must now respond to urgent PAs within 72 hours and standard PAs within 7 days.
Step therapy requires you to try lower-cost drugs first before the plan covers a preferred or higher-tier drug. For example, a plan may require trying generic metoprolol before covering brand-name Bystolic. Federal law limits step therapy for Part D's protected drug classes.
Quantity limits restrict the amount of medication dispensed (pills, units, mLs) within a time period. This prevents overuse, ensures safety, and controls costs. QLs are based on FDA-approved dosing. If you need more than the limit, your doctor must document medical necessity for an exception.
Every denial must come with written notice explaining the reason and your appeal rights. You have a federally protected right to appeal any coverage denial. Medicare beneficiaries have 5 levels of appeal. ACA members have internal and external review rights under the ACA.
From tier structures to protected classes, here's everything you need to navigate drug coverage like an expert.
A drug formulary isn't just a list — it's a financial and clinical framework that determines how much you pay, what restrictions apply, and what rights you have when coverage is denied.
Health plans negotiate with drug manufacturers and pharmacy benefit managers (PBMs) to build formularies that balance member access with cost management.
Most plans use 4–6 tiers. Lower tiers (1–2) contain preferred generics with the lowest copays. Higher tiers (4–5) contain non-preferred brands and specialty biologics with highest cost-sharing. Specialty drugs (Tier 5) often require 25–33% coinsurance with no annual dollar maximum until the OOP limit.
CMS mandates that Medicare plans cover substantially all drugs in six therapeutic categories: immunosuppressants, antidepressants, antipsychotics, anticonvulsants, antiretrovirals, and antineoplastics. Plans cannot restrict access to these with arbitrary PA or step therapy requirements.
Every drug product has a unique 10–11 digit NDC assigned by the FDA. The NDC identifies the labeler (manufacturer), product, and package size. Formulary databases are linked to NDCs — the same drug (same active ingredient) can have different NDCs across manufacturers, affecting formulary status.
Many specialty drug manufacturers offer Patient Assistance Programs (PAPs), copay cards, and foundation grants to reduce cost-sharing. However, in Medicare, manufacturer copay cards may not count toward your true out-of-pocket (TrOOP) limit. Check the plan's coordination of benefits rules.
If your drug isn't on the formulary, you can request a formulary exception asking the plan to cover it. Your prescriber must document that the formulary alternatives are medically contraindicated or would be ineffective for your condition. Plans typically have 72-hour (standard) or same-day (expedited) response requirements.
PBMs (Express Scripts, CVS Caremark, OptumRx) act as intermediaries between insurers, pharmacies, and manufacturers. They negotiate rebates, build formularies, and process claims. PBM contract terms — including rebate pass-through and spread pricing — directly affect formulary design and your costs.
The IRA fundamentally restructured Medicare drug coverage starting 2025. Here's what changed and why it matters for your formulary decisions.
Manufacturers of IRA "selected drugs" pay a new discount to CMS. Plans must include selected drugs on formulary; cost-sharing is capped at the negotiated price.
Plans now bear 60% of costs in the catastrophic phase (vs. 15% before), incentivizing formulary redesign to lower specialty drug spend.
CMS's Premium Stabilization Program reduces how much premium increases as plan liability grows — smoothing benefit design over time.
These free, public APIs power this site and are available for developers, researchers, and advocates. Most require no API key.
FDA's primary public API. Access drug labels (SPL), adverse event reports (FAERS), NDC directory, enforcement/recall data, and drug approval history.
National Library of Medicine's standardized drug nomenclature. Find RxCUI codes, drug interactions, clinical drug names, and relationships between brand and generic drugs.
Official FDA drug labeling repository. Access current prescribing information, package inserts, and structured product labeling (SPL) for approved drugs.
Access Medicare Part D formulary public use files, plan information, drug pricing data, pharmacy networks, and beneficiary cost-sharing details by contract.
ACA Marketplace plans publish machine-readable formulary JSON files per CMS rules. index.json, drugs.json, and plans.json provide tier, PA, and QL data by HIOS Plan ID.
Consumer-friendly drug information from the National Library of Medicine. Covers drug use, side effects, precautions, and interactions in plain language for patients.
FDA's drug shortage database tracks current and resolved drug shortages. Critical for formulary management when a covered drug becomes unavailable and therapeutic substitution is needed.
ClinicalTrials.gov provides data on drug trials, including new therapies that may not yet be on formularies. Patients can access experimental treatments outside formulary restrictions through trial enrollment.
MDRP data shows which manufacturers participate in Medicaid rebates and what unit rebate amounts are reported. Useful for understanding state PDL drug coverage decisions.
Major drug manufacturers offer PAPs, copay assistance, and foundation grants. These programs are outside CMS formulary rules but can significantly reduce your net cost. Note: Medicare beneficiaries may face TrOOP complications with manufacturer cards.