# InsureWith.ai InsureWith.ai is a drug insurance coverage intelligence platform. We help patients, caregivers, benefits managers, and healthcare providers understand how prescription drugs are covered across Medicare Part D, Medicare Advantage, ACA Marketplace plans, Medicaid, and employer/commercial insurance plans in all 50 states. ## What we cover - Medicare Part D formulary data: tier placement, prior authorization requirements, step therapy protocols, and quantity limits for all CMS-regulated plans - ACA Marketplace formulary data: coverage by plan, state, and metal tier from CMS Qualified Health Plan public use files - Private insurance: SBC analysis tool and PBM formulary reference data - Drug cost calculators: patient out-of-pocket estimates accounting for deductible phase, coverage gap, and IRA 2026 $2,000 OOP cap - GLP-1/weight loss drug coverage: Ozempic, Wegovy, Mounjaro, Zepbound coverage by plan type and state - Biosimilar formulary placement tracking - Prior authorization criteria and step therapy protocols ## Tools - Drug Coverage Lookup — https://insurewith.ai/tools/drug-coverage/ (also machine-readable at /tools/drug-coverage/data.json?drug=&state=<2-letter code>): plan-year Medicare Part D and ACA Marketplace formulary tier, prior authorization, step therapy, and quantity limits for a given drug, with NADAC pricing and Medicare Part D spending context. - Coverage Restriction & Exception Navigator — https://insurewith.ai/tools/coverage-exception/ (also machine-readable at /tools/coverage-exception/data.json?drug=&state=<2-letter code>): names the coverage problem (covered / prior authorization / step therapy / quantity limit / not on formulary), gives the exception and appeal path with the CMS-named levels of appeal, who must submit the request, and what to ask the plan and prescriber. Returns typed result_state, per-plan flag counts, an explicit 'unavailable' block for plan-specific clinical criteria and appeal deadlines (which are NOT held and are never inferred), provenance, caveats, safety flags, next_actions and related_tools. - Part D Out-of-Pocket Cap & Payment Plan Simulator — https://insurewith.ai/tools/part-d-cap/ (also machine-readable at /tools/part-d-cap/data.json?monthly=&drug=&deductible=&join=<1-12>): projects month-by-month out-of-pocket spending against the statutory 2026 Part D cap of $2,100, identifies the month the cap is reached, quantifies what the cap itself saves, and compares normal payment timing with the Medicare Prescription Payment Plan — which spreads the same total across the year WITHOUT reducing it. Also reports whether a drug is on Part D formularies and therefore whether spending on it counts toward the cap. Returns typed result_state, assumptions, calculations, evidence with quoted Medicare sources, an explicit 'unavailable' block (plan negotiated price and plan cost sharing are NOT held and are never inferred), data_provenance_classes separating actual plan data / statutory rules / user assumptions / modelled output, caveats, safety flags, next_actions and related_tools. This is a standard-benefit simulation, never a plan-specific pharmacy quote. ## Data sources CMS Part D formulary files, CMS QHP Formulary Public Use Files, FDA OpenFDA, NIH RxNorm, Medicaid NADAC, CMS Medicare Drug Spending data, KFF, AHIP ## Editorial standards All content written by healthcare policy specialists. Medical claims cited to primary sources. Content updated continuously. Not a substitute for professional medical or benefits advice. ## Audience Patients and caregivers seeking drug coverage information. HR professionals and benefits managers. Pharmacists and prescribers. Insurance brokers and advisors. ## Questions Answered Full answers with sources at https://insurewith.ai/questions/ ### Aca Marketplace - How will the 2026 ACA silver plans price GLP‑1 drugs after CMS rule? - How do ACA marketplace formularies decide preferred and specialty drug tiers? - How does the ACA benchmark plan influence prescription drug coverage and networks? - How do ACA marketplace plans handle non-formulary drug exception requests? - How do ACA marketplace plans cover drugs not on formulary? ### Biosimilars - How are PBMs changing formulary rebates for Eylea biosimilars in 2026? - How will UnitedHealthcare’s 2026 formulary treat Humira and its biosimilars? - How are 2026 Medicare Advantage plans prioritizing Amjevita and Cyltezo after CMS billing updates? - How will 2026 ACA Marketplace plans tier Stelara biosimilars after FDA approval? - How will Stelara biosimilars affect 2026 employer drug plan coverage? - How do step therapy and interchangeability rules affect biosimilar substitution? - How do state Medicaid programs decide on mandatory biosimilar substitution? - How do commercial health plans set step therapy rules for interchangeable biosimilars? - Does biosimilar interchangeability affect formulary placement and pharmacy coverage decisions? - Can a health plan require prior authorization for a biosimilar? ### Employer Plans - What triggers mid-year formulary tier changes in employer health plans? - How do self‑funded employers decide which specialty drugs to carve out? - How do employer health plans handle mid-year formulary tier changes? - How do self-funded employer plans handle formulary exception requests for specialty drugs? - How do employer-sponsored health plans handle formulary exception requests? - How do employer plan SBCs show prescription drug cost-sharing rules? - How do employer plans handle non-formulary exceptions when alternatives are inappropriate? - How do PBM rebates affect formulary tiers and drug cost sharing? ### Formulary Changes - How are Medicare Part D formularies changing Eliquis and Xarelto tiers in 2026? - How does a Medicare Part D formulary exception work when my drug isn’t covered? - How do Medicare Part D plans decide formulary tiers for interchangeable biosimilars? - How do Medicare Part D step therapy rules decide drug approval? - How do Medicare Part D plans use prior authorization and step therapy for insulin? - How do Medicare Part D tier exceptions work and when are they reviewed? - How do Medicare Part D protected-class rules limit prior authorization and tiering? - Does a Medicare negotiated drug price change Part D formulary placement and copays? - How does a Medicare Part D transition fill work for non-formulary drugs? ### General - What is a formulary? - What do drug tiers mean? - What is prior authorization? - What is step therapy? - How do I know if my drug is covered by my plan? - What should I do if my drug is denied coverage? - What is the difference between a copay and coinsurance? - How often does formulary data change? ### Glp1 Coverage - How do Medicaid prior authorization rules affect GLP‑1 drug coverage for diabetes versus weight loss? - How do employer plans review GLP-1 prior authorization for obesity coverage? - Does Medicare Part D cover GLP-1 drugs for diabetes but not weight loss? - Do GLP-1 prior authorizations need renewal after initial approval for coverage? - How does Medicare Part D decide coverage for Ozempic weight loss use? ### Glp1 Coverage - Does Medicare cover Ozempic for weight loss? - Which GLP-1 drugs are available and what are they approved for? ### Medicaid - How are state Medicaid programs changing GLP-1 coverage after the 2025 CMS rebate rule? - How do state Medicaid programs handle prior authorization for GLP‑1 weight loss drugs? - How do state Medicaid programs handle prior authorization for GLP‑1 drugs used for obesity versus diabetes? - How do Medicaid managed care carve-outs affect specialty drug coverage rules? - How do Medicaid drug rebates affect preferred drug list placement and prior authorization? - How do Medicaid beneficiaries appeal denied prescription coverage through managed care? ### Medicare Part D - How will Medicare Part D oncology copays change after CMS drug price negotiations? - How do Medicare Part D formulary exceptions and appeals work when a drug isn’t covered? - What costs count toward Medicare Part D catastrophic coverage threshold? ### Medicare Part D - What is the Medicare Part D coverage gap? - How does the $2,000 out-of-pocket cap work in 2026? ### Prior Auth - How are Medicare plans handling prior authorization for Leqembi and Kisunla in 2026? - How are 2026 ACA marketplace plans changing prior authorization for GLP‑1 weight‑loss drugs? - How are urgent 72-hour prior authorization drug requests processed and approved? - What documentation is needed for an expedited prior authorization request? - How do specialty drug prior authorization criteria separate step therapy and contraindications? ### Sbc - What is an SBC and where do I find mine?