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Coverage CheckPlan ComparisonLearnMedicare GuideFor Employers
Updated with 2026 CMS data

Know what your plan actually covers

Enter your drug and your plan. Get the real answer — tier placement, exact copay, restrictions, and cheaper alternatives your plan already covers. Powered by CMS formulary data for every Medicare Part D and ACA Marketplace plan.

5,200+
Part D Plans
190K+
Drug Combos
Monthly
CMS Refresh
Rx
Coverage Lookup
Check any drug on any plan
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Data from CMS.gov · Updated monthly · Pricing via RxPBM.ai
Federal data sources
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Results: Ozempic (Semaglutide)

✓
Coverage Status
SilverScript Choice · PA
CoveredOn formulary as semaglutide injection

Covered but placed on a high-cost tier with restrictions that affect your out-of-pocket cost.

T
Formulary Tier
Cost ladder position
T1
T2
T3
T4
T5
Tier 4 — Non-Preferred Brand
Second-highest cost tier. GLP-1 agonists land here because rebate agreements don’t offset enough of the list price for preferred status.
Ri
Why is it on Tier 4?How formulary tier decisions work → RxInfo.ai
$
Your Estimated Cost
After $590 deductible
Preferred Pharmacy$142/mo
Non-Preferred Pharmacy$198/mo
Mail Order (90-day)$380/qtr
2026 OOP Cap$2,000
Pb
Full pricing breakdownPlan pays $892 · Pharmacy gets $847 · See spread → RxPBM.ai
!
Restrictions
Requirements for coverage
PA · Prior Auth RequiredQL · Qty Limit: 30-day

Prior Authorization: Prescriber must submit documentation showing medical necessity. Typical approval: 24–72 hours.

Quantity Limit: 1 pen (4 doses) per 30-day fill. 90-day via mail order.

↓
Lower-Cost Alternatives on Your Plan
Same therapeutic class, lower tier
Metformin ER 1000mg
Tier 1 · Preferred Generic · No restrictions
$0–$4
Trulicity (dulaglutide)
Tier 3 · Preferred Brand · Prior auth
$47/mo
Rybelsus (oral semaglutide)
Tier 3 · Preferred Brand · Step therapy
$52/mo
Jardiance (empagliflozin)
Tier 3 · Preferred Brand · No restrictions
$47/mo
Cx
2 biosimilars in pipelinePhase 3 trials, est. 2027–2028 → ClinicalRx.ai
Ri
Compare these medicationsClinical profiles and side effects → RxInfo.ai
→
What You Can Do Next
Actions to reduce your cost
Dr
Find a specialistEndocrinologist for alternatives or appeal → DrFinder.ai
Sv
Manufacturer savingsNovo Nordisk savings card for eligible patients → RxSaver.ai
Rb
Benefits breakdownFull copay math and tier structure explained → RxBenefits.ai
How It Works
Real coverage data.
Not estimates.
We pull directly from CMS formulary files — the same data your insurance company submits to the federal government.
01
Enter your medication
Brand or generic. We match against the CMS Formulary Reference File using NDC and RxNorm identifiers.
02
Identify your plan
State, insurance type, plan name. We search 5,200+ Medicare Part D plans and ACA Marketplace formularies.
03
Get the real answer
Tier placement, copay amounts, prior auth, quantity limits — from the latest CMS monthly release.
04
See the full picture
Pricing from RxPBM.ai, pipeline from ClinicalRx.ai, specialists from DrFinder.ai — all connected.
Our Data
Federal formulary data,
updated monthly.
Every result comes from publicly filed, government-mandated sources. No scraping, no estimates, no stale caches.
D
Medicare Part D Formulary Files
Monthly CMS downloads with every drug covered by every Part D and MA-PD plan — tier placement, copay structure, PA flags, step therapy, and quantity limits. 5,200+ plans indexed.
A
ACA Marketplace Formularies
Machine-readable JSON from every QHP issuer on Healthcare.gov — drug coverage, tier classification, and cost-sharing per the CMS QHP schema standard.
$
Beneficiary Cost Files
Plan-level cost sharing for preferred, non-preferred, and mail order pharmacies. Copays, coinsurance, deductible exclusions, and the 2026 $2,000 out-of-pocket cap.
Insurance Education
Understand your coverage.
Make smarter decisions.
Insurance is deliberately confusing. These guides explain what actually matters for your wallet.
Formulary Basics

What Is a Formulary Tier and Why Does It Decide What You Pay?

Plans group drugs into 5 tiers. Tier placement has more to do with rebate negotiations than medical value.

Read the guide →
Prior Authorization

Your Doctor Prescribed It. Why Is Insurance Saying No?

Prior auth means your plan wants proof of medical necessity. What triggers it, how appeals work, and your rights.

Read the guide →
2026 Changes

The $2,000 Cap Is Here. What the IRA Limit Means for You.

Medicare Part D now has a hard $2,000 annual cap. But plans are restructuring tiers and shifting to coinsurance.

Read the guide →
Common Questions
How this works and
what to expect.
Yes. We pull from the same CMS Formulary Reference Files that pharmacies and plan sponsors use. The tier placement, prior authorization flags, and quantity limits come directly from the plan’s filed formulary. Copay amounts reflect the cost-sharing structure the plan submitted to CMS.
CMS releases updated formulary files monthly. We sync within 48 hours of each release. Plans can change tier placement, add or remove drugs, and adjust cost-sharing mid-year — those changes appear here as soon as CMS publishes them.
Several factors can cause differences: where you are in your deductible cycle, whether the pharmacy is preferred or non-preferred in your plan’s network, manufacturer copay cards applied at the register, or mid-year formulary changes. The amounts shown here are the plan’s filed cost-sharing structure before any external discounts.
Currently, our deepest coverage is Medicare Part D and ACA Marketplace plans, which are required to file formulary data publicly with CMS. Employer-sponsored plans are not required to make their formularies public. We’re building partnerships to bring employer plan data into the tool — check back or sign up for updates.
Free, no account required, no ads. InsureWith.ai is part of the BuiltForAI healthcare ecosystem. The coverage tool helps consumers understand their plans. Connected services like RxPBM.ai and DrFinder.ai generate revenue through provider referrals and B2B data products, not by selling your information.