Your Prescription Drug Costs Depend on Where You Live and Who's Paying

At least 25 million Americans lost Medicaid coverage during the 2023 to 2024 unwinding, according to KFF's Medicaid Enrollment and Unwinding Tracker. Nearly seven in 10 lost coverage for paperwork reasons rather than actual ineligibility. Millions more must meet new Medicaid work requirements starting late 2026. The coverage loss compounds an already large uninsured population: 27.1 million Americans lacked coverage in 2024, with 42% concentrated in just 10 non-expansion states. For those affected, knowing how to get health insurance is a starting point, but access and affordability remain uneven.

A patient managing diabetes, blood pressure and depression pays $15 per month on Medicaid. Paying cash in the most expensive cities, those same medications run $425. Even in the cheapest markets, cash prices hit $237 monthly.

For a patient on two medications, the gap runs from $6 monthly on Medicaid to $124 cash in expensive cities, or $78 in cheaper ones.

This analysis uses three data sources. The Commonwealth Fund's October 2025 Medicare State Scorecard covers 65 million Medicare beneficiaries and ranks all 50 states on drug affordability — Alaska leads, North Dakota trails. Beneficiaries in North Dakota pay more than four times the cost share of those in Alaska. The Health Care Cost Institute tracks employer insurance spending for 40 million Americans, though its state-level data isn't publicly accessible. GoodRx's 2024 analysis of 30 major cities found a 56-point spread in cash prices, with Denver 37% below the national average and Little Rock 19% above.

Little Rock, Arkansas, shows what happens when policy gaps accumulate. Arkansas didn't expand Medicaid, has one of the nation's highest uninsured rates, and posts cash prescription prices 19% above the national average — leaving residents with fewer coverage options than those in expansion states.

Denver, Colorado, went the other direction. It expanded Medicaid, created a Prescription Drug Affordability Board to set price caps, and now posts cash prices 37% below the national average.

Coverage type outweighs geography in prescription drug costs, but geography still shapes what people pay within each coverage type. On Medicaid, insulin runs about $3. Paying cash in Little Rock, that same insulin costs $110. Medicare beneficiaries in Alaska pay roughly half what those in North Dakota pay. For cash payers, the same prescriptions cost $188 more per month in Little Rock than in Denver.

Medicare Part D is a federal program, but what beneficiaries pay varies widely by state. The Commonwealth Fund's State Scorecard on Medicare Performance, published in October 2025, ranks all 50 states plus Washington, D.C., on prescription drug affordability.

Alaska leads on prescription drug affordability. Vermont, Utah and Minnesota rank highest for overall Medicare performance across all measures, but Alaska takes first place on drug costs alone. Medicare beneficiaries in Alaska pay an average of $254 annually out-of-pocket for Part D drugs and cover just 4.4% of total drug costs.

Washington, D.C., ranks second for drug affordability. Its Medicare beneficiaries pay $216 annually out-of-pocket and cover 3.0% of total drug costs.

North Dakota ranks 51st — last — for drug affordability. Its beneficiaries pay $506 annually out-of-pocket and cover 12.8% of drug costs. Compared to Washington, D.C., North Dakota beneficiaries shoulder 4.3 times the cost share and pay 2.3 times more out-of-pocket.

The top five states for prescription drug affordability are Alaska, Washington, D.C., Arizona, Hawaii and Maine. The bottom five are Nebraska, South Dakota, Oklahoma, Kansas and North Dakota.

Drug affordability rankings don't follow overall Medicare performance. Alaska ranks 41st in overall Medicare performance but first in drug costs. Washington, D.C., ranks 30th overall but second for drug affordability. North Dakota ranks 21st overall but last for drug costs. Nebraska ranks 15th overall but 47th for drug affordability. State policy choices and pharmacy market dynamics appear to drive drug cost variation independent of broader Medicare quality.

MoneyGeek's 2026 Best States for Health Care rankings show wide gaps in outcomes and costs. States performing well on overall health care can still leave Medicare beneficiaries exposed to high medication costs. Others rank poorly overall but lead on drug affordability.

GoodRx analyzed prices through its discount program for the 500 most commonly prescribed medications across 30 major U.S. cities and 70,000 pharmacies in 2024. The data shows a 56-point spread from the most to least expensive markets.

Denver ranks cheapest at 37% below the national average. Houston and Dallas run 26% and 17% below. Atlanta, Tampa and Orlando range from 12% to 21% below.

Little Rock ranks most expensive at 19% above average. New Orleans and New York City both run 18% above. Milwaukee, Lexington, Los Angeles and San Francisco exceed the national average by 9% to 16%.

Cost of living doesn't explain the pattern. Denver has high living costs but the cheapest drugs. Atlanta has high living costs but ranks 21% below average. New York City has both high living costs and high drug prices. Houston, with moderate living costs, has some of the nation's cheapest medications.

Texas cities cluster at the low end (Houston 26% below, Dallas 17% below), pointing to state-level factors like pharmacy competition as drivers of regional differences. California cities cluster at the high end (Los Angeles 13% above, San Francisco 9% above), though San Diego sits closer to average at 8% above.

Medicaid copay requirements fell sharply between 2019 and 2023. KFF's 2024 survey shows about half of states now require copays for at least some drug categories, down from roughly three-quarters in 2019. Twenty-six states eliminated copays entirely, including California, Illinois and Ohio.

Low-copay states charge $1 to $3 for generic drugs; moderate-copay states charge around $4. Federal rules exempt children under 18, pregnant women, nursing home residents and emergency services. Many states also exempt HIV medications, substance use disorder treatments, mental health drugs and vaccines.

The cost scenarios below use five common chronic medications. Multiple chronic conditions (diabetes, high blood pressure, high cholesterol and depression) are common among older adults and people with complex health needs, and costs can reach the intensive levels shown.

Losing Medicaid in Little Rock means jumping from $6 to $124 monthly for two medications ($1,416 annually), or from $15 to $425 for five medications ($4,920 annually). Even in Denver, five-drug costs jump from $15 to $237 monthly ($2,664 annually). Newly uninsured patients typically turn to the most affordable health insurance options.

All prices are retail cash costs without discount cards. Manufacturer assistance programs and pharmacy discount cards like GoodRx can cut costs. Sanofi offers insulin for $35 monthly through its Valyou Savings Program, and GoodRx coupons can lower generics to $8 to $15 for 30-day supplies.

Those programs require enrollment, awareness and pharmacy acceptance. Many newly uninsured people hit retail prices before learning alternatives exist.

As more states dropped copays entirely between 2019 and 2023, the drop got sharper. People now go from $0 to hundreds of dollars monthly when they lose Medicaid.

The Health Care Cost Institute reports $1,563 in national per-person prescription drug spending for 2022, based on claims from Aetna, Humana, Kaiser Permanente and UnitedHealthcare covering 40 million people. That figure doesn't include average health insurance costs, which vary just as widely by state.

The data gap compounds a broader affordability problem. ACA premiums jumped 20% nationally for 2026, with some states seeing increases as high as 67%. Nearly one in five in-network ACA claims are denied even with coverage, leaving enrollees paying out of pocket. Knowing how to appeal a denied claim can recover some of those costs.

State-level employer drug data exists but isn't publicly accessible. HCCI's state health spending tool shows aggregate data, but detailed state-by-state prescription costs require individual purchase. Some states sell extracts from their all-payer claims databases, but these are costly and incomplete.

The Employee Retirement Income Security Act exempts self-insured employer plans from state reporting requirements. These plans cover 60% of the employer insurance market, roughly 95 million Americans. Even in the 25 states with all-payer claims databases, ERISA prevents states from compelling self-insured plans to report.

The national $1,563 average hides state variation we can't measure for these 95 million Americans.

Medicare Part D operates under federal rules, but states influence drug costs through supplemental programs, pharmacy networks and market conditions.

Medicare beneficiaries in Alaska pay $254 annually out-of-pocket for Part D drugs. Those in North Dakota pay $506, more than double. Both have Medicare Part D, but state-level factors produce a $252 annual difference.

Cash prices show the widest spread. For five medications, prescriptions cost $425 monthly in Little Rock but $237 in Denver, a $188 monthly difference or $2,256 annually. For two medications, the gap is $124 in Little Rock versus $78 in Denver, a $46 monthly difference or $552 annually.

State policy accounts for some of the variation. Colorado's Prescription Drug Affordability Board can set price caps on high-cost drugs. Minnesota publishes drug pricing transparency reports. Oregon requires manufacturers to report price increases above certain thresholds.

Market forces drive much of it. Opaque drug pricing and pharmacy benefit manager rebates can push costs up without reducing what patients pay, similar to how the ACA's medical loss ratio rule can inadvertently reward insurers when spending climbs. States with more Part D plan options tend to see more competitive pharmacy rates. Some also offer low-income assistance beyond federal subsidies, while others have denser pharmacy networks that keep prices lower.

Pharmacy density matters, too. Rural states with fewer pharmacies have less competition, pushing prices up. Urban states with dense pharmacy networks and mail-order access generally see lower costs. Alaska's affordability lead is notable given its geographic isolation — the state's assistance programs appear to offset limited market competition. Texas cities cluster at the lower end of the cost range, likely driven by highly competitive local pharmacy markets.

Employer-sponsored insurance covers roughly 160 million Americans, but state-level drug cost data for this group isn't publicly accessible. HCCI's national average of $1,563 annually hides differences we can't measure.

This analysis covers prescription drug costs across three populations using the most recent data available for each. Medicare data runs through October 2025. Employer insurance data runs through 2022 to 2023. Cash price data was published in 2024.