Original Medicare Part A and Part B limit coverage of prescription drugs. Medicare Part A may cover painkillers if you require them while you are formally admitted as an inpatient at a hospital or other Medicare-approved facility. Medicare Part B coverage of medication is restricted to drugs administered at a doctor’s office or in an outpatient setting at a hospital. It is not intended to cover prescription drugs taken orally at home.
Prescription drug coverage is available to Medicare recipients through a Medicare Part D drug plan. You have a choice between enrolling in a stand-alone Medicare Prescription Drug Plan (PDP) that works with Original Medicare or enrolling in a Medicare Advantage plan that includes prescription drug coverage. MA plans are required to provide at least the same benefits as Original Medicare but many offer additional benefits, such as prescription drug benefits.
Does My Medicare Part D Plan Cover Pain Medication?
Every prescription drug plan has a formulary, or list of the prescription drugs the plan covers. The formulary will include both generic and brand-name drugs. The formulary can change, but your plan is required to notify you of any changes. Each plan will have its own tiers of pricing and cost-sharing responsibilities. Generic medications tend to be less expensive than brand-name medications, so find out from your doctor if your condition requires a specific brand-name medication or if you can substitute a generic drug.
Safety for Opioid Pain Medication
Opioid medication, like Hydrocodone and Oxycodone, can be prescribed to alleviate specific types of pain, but there are serious risks that come with their use, including overdose, addiction, and even death. Drug plans for Medicare benefits oversee the safe use of these and other frequently abused prescription drugs.
As of January 1, 2019, the Centers for Medicare & Medicaid Services (CMS) requires Part D plans to follow an opioid policy to combat the opioid epidemic. This policy encourages safe use of painkillers, the prevention of new cases of opioid use disorder (OUD), and treatment of patients who have become addicted. This policy is not intended to keep medically necessary medications away from patients who need them. Instead, the provisions will allow patients to have access to medications they need and protect them from addiction and overuse.
Decisions regarding prescription painkillers must be based on the medically necessity of the individual patient. If you disagree with a decision your plan makes, you and your doctor have the right to contact the plan to ask for a coverage determination, including the right to request an expedited or standard coverage determination in advance of prescribing an opioid. Medicare recipients who reside in a long-term care facility, are in hospice, or have cancer, could be excluded from the interventions.
Pharmacy Safety Alerts
Specific prescriptions may trigger additional safety checks. Before your prescription gets filled, your Prescription Drug Plan could send an alert to your pharmacy for review. Situations that may trigger a safety alert may include:
- Use of benzodiazepines and opioids at the same time.
- Filling an opioid prescription for the first time. You could receive a limited supply, normally 7 days.
- Potentially unsafe amounts of opioids. Your Medicare drug plan or pharmacist may require a review with your doctor to confirm the safety of the dosage.
Talk to your doctor and discuss all the available pain treatment options for your specific illness or injury. There may be alternative options and other types of medications that may help manage your pain.
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