Medicare does cover Actos, but almost always in its generic form. Generic pioglitazone, the active ingredient in Actos, appears on the formularies of most Medicare Part D prescription drug plans, usually on a low generic tier with modest copays. Brand-name Actos is generally not covered, and when a plan does list it, the brand sits on a higher tier with much steeper cost-sharing.
Because the generic is therapeutically equivalent and far cheaper, plans steer beneficiaries toward it. Brand-name Actos can run around $500 for a 30-day supply, while generic pioglitazone typically costs between roughly $6 and $18 per month at retail, depending on dosage and pharmacy.
Where Pioglitazone Sits on Part D Formularies
Each Part D plan sets its own formulary and tier structure, so the exact placement varies. Generic pioglitazone commonly lands on Tier 2 (generic drugs), where the typical copay runs from $0 to $20 for a 30-day supply. Some plans charge coinsurance of 0% to 25% instead of a flat copay. At least one Medicare plan reviewed placed generic pioglitazone at Tier 1, the lowest cost tier, while listing brand-name Actos at Tier 3.
Pioglitazone is an oral tablet, so it is covered under Part D only. Medicare Part B does not pay for oral diabetes medications. For diabetes, Part B covers insulin only when used with an insulin pump that qualifies as durable medical equipment. If you have Original Medicare, you need a standalone Part D plan to get coverage for pioglitazone. If you are enrolled in a Medicare Advantage plan that includes drug coverage, your Part D benefit runs through that plan, and the same formulary and tier rules apply.
Medigap matters here too, in the negative. Medicare Supplement plans sold after 2005 do not include prescription drug benefits, so a Medigap policy will not help pay for pioglitazone. Drug coverage still has to come from Part D.
What You’ll Actually Pay in 2026
Part D coverage runs in three stages during the calendar year, and your out-of-pocket cost for pioglitazone depends on which stage you are in.
- Deductible stage. You pay the full negotiated price of covered drugs until you meet the plan’s deductible, which can be up to $615 in 2026. Some plans set a $0 deductible, and many exempt generics from the deductible entirely, which often means pioglitazone copays start right away.
- Initial coverage. After the deductible, you pay 25% coinsurance (or the plan’s copay) on covered drugs until your out-of-pocket spending reaches $2,100.
- Catastrophic coverage. Once you hit the $2,100 annual out-of-pocket cap, you pay $0 for covered Part D drugs for the rest of the year.
The $2,100 cap was created by the Inflation Reduction Act. It was $2,000 in 2025 and adjusts annually. The cap includes deductibles, copays, and coinsurance for drugs on your plan’s formulary, but it does not include your monthly plan premium or the cost of drugs the plan doesn’t cover. For someone taking only pioglitazone and no other expensive medications, annual spending will usually stay well below the cap given the generic’s low price.
One cap that does not help here: the $35 monthly insulin cap. The Inflation Reduction Act limited Medicare cost-sharing to $35 per month per covered insulin product, but CMS has stated plainly that the $35 limit applies only to insulin. Pioglitazone, like other oral diabetes drugs, is subject to the regular Part D tiers and the $2,100 annual cap instead.
Confirming Coverage for Your Specific Plan
Formularies change year to year and vary widely between plans, so the only reliable way to see what you’ll pay is to check your own plan. The Medicare Plan Finder at medicare.gov/plan-compare is built for this. Enter your ZIP code, add pioglitazone to your drug list, and select your preferred pharmacies. The tool then shows which plans in your area cover the drug, which pharmacies are in network, and what you would pay at each coverage stage.
If you are already enrolled, you can also pull your plan’s current formulary document directly from the plan’s website or call member services and ask whether pioglitazone is covered, what tier it sits on, and whether any restrictions apply.
If Your Plan Won’t Cover Pioglitazone or Adds Restrictions
Some plans require prior authorization for pioglitazone or impose step therapy, meaning you have to try another drug first. These restrictions are partly a response to FDA safety warnings on pioglitazone, including a boxed warning for congestive heart failure and warnings about bladder cancer risk with long-term use. If your plan flags the drug, your prescriber will need to work with the plan directly.
You have a few options when a plan won’t cover pioglitazone or wants to limit access to it.
Request a formulary exception. You or your prescriber can ask the plan to cover pioglitazone even if it is not on the formulary. Your doctor has to submit a supporting statement that the drug is medically necessary, that formulary alternatives would be less effective or cause adverse effects, or that you have already tried alternatives without success. If the plan grants the exception, it must cover the drug under normal cost-sharing rules and cannot force a new approval for each refill as long as the prescription stays active.
Appeal a denial. If the plan denies the exception, you can appeal. If the plan misses the required decision deadline, that failure is treated as an adverse determination and sent to an Independent Review Entity within 24 hours.
Switch plans during Open Enrollment. Medicare’s annual Open Enrollment Period runs October 15 through December 7, with new coverage effective January 1. You can use that window to move to a plan that covers pioglitazone on better terms.
Ways to Lower the Cost Further
Extra Help
Medicare’s Extra Help program (the Low-Income Subsidy) assists Part D enrollees with limited income and resources. In 2026, qualifying beneficiaries pay $0 in plan premiums and deductibles, with copays capped at $5.10 per generic drug and $12.65 per brand-name drug. Once total drug costs reach $2,100, copays drop to $0 for the rest of the year. Beneficiaries who also have full Medicaid and are in the Qualified Medicare Beneficiary program pay no more than $4.90 per covered drug.
Eligibility for 2026 is based on income up to $23,940 for an individual or $32,460 for a married couple, with resource limits of $18,090 and $36,100 respectively. People with full Medicaid, Supplemental Security Income, or state help paying Part B premiums qualify automatically. Everyone else applies through the Social Security Administration, and you can apply at any time.
State Pharmaceutical Assistance Programs
At least 48 states run State Pharmaceutical Assistance Programs that help with prescription costs beyond what Part D covers. Many coordinate directly with Part D by paying premiums, deductibles, or copays, and payments made through these programs count toward your Part D out-of-pocket maximum. Rules vary by state. Pennsylvania’s PACE and PACENET, New Jersey’s Pharmaceutical Assistance to the Aged and Disabled, and California’s Prescription Drug Discount Program for Medicare Recipients are examples. Check what’s available in your state through medicare.gov.
Medicare Prescription Payment Plan
Since 2025, every Part D plan has to offer the Medicare Prescription Payment Plan, which lets you spread out-of-pocket drug costs across the calendar year in monthly installments instead of paying larger sums at the pharmacy. Enrollment is voluntary and free. Once you’re enrolled, you pay $0 at the pharmacy and the plan sends you a monthly bill. The program doesn’t lower drug prices or reduce total costs; it only reshapes when you pay. You can enroll at any time by contacting your plan, and enrollment renews automatically each year unless you opt out or switch plans.