Health Insurance Coverage and Restrictions on Prescription Medications in 2025

Health insurance coverage for prescription medications has seen a decline in accessibility and an increase in restrictions over the past decade, according to data from GoodRx. In 2025, insurance covered 56% of medications, down from 61% in 2015, while restrictions such as prior authorizations affected 49% of medications, up from 39% a decade prior.

This trend reflects tighter controls on drug formularies, impacting patient access to prescribed treatments. However, slight improvements were noted from 2024 to 2025, with a 2% increase in coverage and a 1% decrease in restrictions.

Medicare patients face more pronounced coverage challenges, with 44% of medications not covered and restrictions on 49%, compared to 21% and 35% respectively for commercial insurance. Medicaid offers broader coverage at 97%, but 63% of these medications still come with restrictions.

Pharmacy Benefit Managers (PBMs) play a pivotal role in these coverage decisions, as they control drug formularies and negotiate coverage terms with manufacturers on behalf of insurers and health plans. Recent years have seen a sharp rise in drugs excluded from formularies by major PBMs, which has amplified administrative hurdles for patients and providers alike.

Physicians report that sudden changes in coverage disrupt patient care, highlighting the impact of PBM-driven formulary adjustments on continuity of treatment. Regulatory oversight remains limited, allowing health plans significant latitude in altering medication coverage annually. This regulatory gap contributes to ongoing challenges in medication affordability and accessibility for insured patients, emphasizing the need for closer scrutiny of formulary management and PBM practices within the health insurance sector.