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

At least 25 million Americans lost Medicaid coverage during the 2023-2024 unwinding, according to KFF's Medicaid Enrollment and Unwinding Tracker, and nearly 7 in 10 lost coverage for paperwork reasons rather than actual ineligibility. Now millions more must meet new Medicaid work requirements starting late 2026. This compounds an existing crisis: 27.1 million Americans were uninsured in 2024, with 42% concentrated in just 10 non-expansion states. For those who lost coverage, getting health insurance is an urgent matter.

For someone managing multiple chronic conditions, taking insulin, blood pressure medication and an antidepressant, this coverage disruption can mean jumping from $15 per month on Medicaid to $425 per month paying cash in the most expensive cities. Even in the cheapest markets, cash prices can hit $237 monthly.

For someone on just two medications, the jump is from $6 monthly on Medicaid to $124 cash in expensive cities or $78 in cheaper markets.

We analyzed three separate data sources to map prescription drug costs across coverage types. The Commonwealth Fund's October 2025 Medicare state scorecard shows 65 million Medicare beneficiaries experience largely different drug costs depending on their state. Alaska ranks first for drug affordability while North Dakota ranks last, with North Dakota beneficiaries shouldering more than four times the cost share. The Health Care Cost Institute tracks employer insurance spending for 40 million Americans, but state-level data remains largely inaccessible to the public. GoodRx's 2024 analysis of 30 major cities found a 56-point spread in cash prices, with Denver running 37% below the national average and Little Rock 19% above.

The state-level disparities are clear and consequential. Little Rock, Arkansas sits at the intersection of multiple affordability crises: Arkansas didn't expand Medicaid, has one of the nation's highest uninsured rates, and shows cash prescription prices 19% above the national average. For those seeking coverage in the state, Arkansas health insurance options remain limited compared to expansion states. Denver, Colorado tells a different story: Medicaid expansion, a Prescription Drug Affordability Board setting price caps, and cash prices 37% below the national average. Same medications, vastly different costs depending on where you live and who pays.

The fragmentation is the story. Coverage type determines cost more than geography, but within each coverage type, geography creates meaningful variation. Your insulin costs $3 on Medicaid but $110 paying cash in Little Rock. Medicare beneficiaries in Alaska pay half what those in North Dakota pay. The same prescriptions cost $188 more monthly in Little Rock than Denver for cash payers.

Medicare Part D is a federal program, but state-level differences in drug affordability are substantial. The Commonwealth Fund's State Scorecard on Medicare Performance, published in October 2025, ranks all 50 states plus the District of Columbia on prescription drug affordability. For those new to understanding what Medicare covers, these state-level cost differences can be surprising.

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

DC ranks second for drug affordability with the lowest costs in the nation. Its Medicare beneficiaries pay just $216 annually out-of-pocket and cover only 3.0% of total drug costs.

North Dakota ranks last at 51st for drug affordability. Its Medicare beneficiaries pay $506 annually out-of-pocket and cover 12.8% of drug costs. Compared to DC, 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, DC, Arizona, Hawaii and Maine. The bottom five are Nebraska, South Dakota, Oklahoma, Kansas and North Dakota.

The disconnect between overall Medicare performance and drug affordability is striking. Alaska ranks 41st in overall Medicare performance but first in drug costs. DC ranks 30th overall but second for drug affordability. North Dakota ranks 21st overall but dead last at 51st for drug costs. Nebraska ranks 15th overall but 47th for drug affordability. These outliers suggest state policy choices or pharmacy market dynamics drive drug cost variation independent of broader Medicare quality.

Our 2026 Best States for Health Care rankings show large gaps in outcomes and costs across all dimensions. This drug-cost analysis reveals that some states performing well on overall health care still leave Medicare beneficiaries or cash-pay patients exposed to high medication costs, while others excel at drug affordability despite middling performance elsewhere.

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

Denver ranks cheapest at 37% below the national average. Houston and Dallas run 26% and 17% below average. 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 also 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, offers some of the nation's cheapest medications.

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

Medicaid copay requirements dropped substantially 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.

We built cost scenarios using common chronic medications. Many patients take fewer medications than the examples below. For those managing multiple chronic conditions (diabetes plus blood pressure plus cholesterol plus depression isn't uncommon among older adults or people with complex health needs), costs can reach these intensive levels.

Losing Medicaid coverage in Little Rock means jumping from $6 to $124 monthly for two medications ($1,416 annually) or $15 to $425 for five medications ($4,920 annually). Even in Denver, five-drug costs jump from $15 to $237 monthly ($2,664 annually). For those losing coverage, finding the most affordable health insurance is a high priority. 

These prices reflect retail cash costs without discount cards. Manufacturer assistance programs and pharmacy discount cards like GoodRx can reduce costs. For example, 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.

But these programs require enrollment, awareness and pharmacy acceptance. Many newly uninsured people encounter retail prices first, creating immediate financial stress.

The 2019 to 2023 copay reduction trend makes this cliff steeper. More states eliminated copays entirely, meaning people go from $0 to hundreds of dollars monthly when they lose coverage.

Employer-sponsored insurance covers roughly 160 million Americans. The Health Care Cost Institute reports national per-person prescription drug spending of $1,563 annually for 2022, based on claims from Aetna, Humana, Kaiser Permanente and UnitedHealthcare covering 40 million people. When combined with average health insurance premim costs, the total financial burden on families mounts quickly.

The affordability picture extends beyond drug costs. ACA premiums jumped 20% nationally for 2026, with some states seeing increases as high as 67%. Even with coverage, nearly 1 in 5 in-network ACA claims are denied, leaving many people paying out of pocket. Knowing how to appeal a health insurance claim denial can help recover these unexpected 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. Even within the same coverage category, geography creates cost differences.

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 create 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 difference is $124 in Little Rock versus $78 in Denver, a $46 monthly gap or $552 annually.

State policy explains some 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.

But market factors matter more. Just as the ACA's medical loss ratio rule can unintentionally reward insurers when spending rises, opaque drug pricing and pharmacy benefit manager rebates can let costs climb without lowering what patients pay. Some states offer additional low-income assistance beyond federal subsidies. Others have higher pharmacy concentrations, creating competition that lowers prices. Plan availability varies by state. Competitive markets with many Part D choices push insurers to negotiate lower pharmacy rates.

Geographic pharmacy concentration plays a role. Rural states with fewer pharmacies see higher prices due to limited competition. Urban states with dense networks and mail-order options have lower costs. Alaska's top ranking despite geographic challenges suggests generous state assistance programs outweigh market limitations. Texas cities cluster at the low end likely due to competitive pharmacy markets.

The employer insurance data gap means we can't quantify state variation for 160 million Americans with job-based coverage. HCCI's national average of $1,563 annually hides differences we can't measure.

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