Drug Coverage: What Your Insurance Really Won't Tell You
When you hear drug coverage, the extent to which your health insurance pays for prescription medications. Also known as prescription drug benefits, it's not just a list of covered pills—it's a maze of rules, hidden barriers, and shifting priorities that can leave you paying more than you expected. Most people assume if a drug is FDA-approved, their insurance will cover it. That’s not true. Even common, cheap generics like gabapentin or losartan can be blocked, restricted, or require paperwork just to get filled.
Prior authorization, a process where your insurer demands proof before approving a medication is now routine—even for generics. Why? Because insurers are pushing patients toward the cheapest option on their formulary, the official list of drugs covered by a health plan. Also known as preferred drug list, this list isn’t based on what works best for you—it’s based on what costs the least to the insurance company. A drug might be clinically identical to a brand-name version, but if it’s not on the formulary, you’re stuck paying full price. And formularies change all the time. In 2025, Medicare and private plans are moving more drugs to higher tiers, adding step therapy, and dropping generics without warning.
It’s not just about cost. Generic medications, FDA-approved copies of brand-name drugs that work the same but cost far less are often the solution—but they’re not always easy to get. Some insurers delay coverage for years after a patent expires, thanks to legal loopholes and corporate deals. Even when generics are available, you might still need to try three other drugs first. And if you’re on a specialty drug like selegiline or Rybelsus, the paperwork can take weeks.
What’s missing from the conversation? Your voice. You don’t have to accept a denial. You can appeal. You can ask your pharmacist to check for formulary exceptions. You can switch plans during open enrollment. And you can push back when a drug you’ve been on for years suddenly disappears from coverage. The posts below break down exactly how this system works—why your insurance blocks certain meds, how to fight back, what to ask your pharmacist, and how to avoid surprise bills. No fluff. No jargon. Just what you need to know to get the drugs you need without getting buried in red tape.
