Does Medicare cover Fentanyl?

Steven Mott by Steven Mott | Licensed since 2012
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This article was updated on: 09/10/2018

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What is Fentanyl?

Fentanyl is in a class of medications called narcotic (opiate) analgesics. It works by changing the way the brain and nervous system respond to pain, according to the U.S. National Library of Medicine.

When is Fentanyl used?

Doctors who are treating pain associated with cancer may prescribe Fentanyl. Fentanyl is used to treat breakthrough pain (sudden episodes of pain that occur despite round-the-clock treatment with pain medication) in cancer patients. Fentanyl could cause serious breathing problems and even death and should not be used to treat pain from migraines, injury, or dental procedures, according to the U.S. National Library of Medicine.

Does Medicare cover Fentanyl?

If you are enrolled in a Medicare Part D Prescription Drug Plan or a Medicare Advantage plan that provides Part D prescription drug coverage, the plan may cover Fentanyl.

Medicare Part D prescription drug benefits are available from private insurance companies contracted with Medicare.  Usually you can choose to receive Part D prescription drug coverage by enrolling in a stand-alone Medicare Part D Prescription Drug Plan or in a Medicare Advantage Prescription Drug plan.

Both types of Medicare plans providing Part D prescription drug coverage have formularies, or lists of covered medications.  Formularies usually include brand-name prescription drugs and their generic equivalent medications.  Usually prescription drug plans assign benefit tiers to their formularies. You pay a specific copay or coinsurance amount for a covered medication based upon its placement within the formulary tiers.  Generic prescription drugs are typically less expensive than brand-name prescription drugs. For example, Fentanyl may be available as a generic prescription drug at a lower out-of-pocket cost than as a brand-name medication under the names Abstral®, Actiq®, Fentora®, or Onsolis®. Formularies may change at any time and your plan will notify you when necessary.

Are there restrictions or limitations to Medicare coverage for Fentanyl?

As is the case with most prescription drugs, Original Medicare, the program administered by the federal government, provides very limited coverage for Fentanyl.  Medicare Part A (hospital insurance) may help pay for Fentanyl you receive during an inpatient stay for cancer treatment at a Medicare-certified hospital.  Medicare Part B (medical insurance) usually does not cover the cost of prescription drugs you take orally such as Fentanyl. Medicare Part B generally does cover some types of infusions and injections. In general, you must be enrolled in a stand-alone Medicare Part D Prescription Drug Plan or a Medicare Advantage Prescription Drug plan to receive Medicare benefits for Fentanyl.

Most Medicare plans offering Part D prescription drug coverage place restrictions or limitations on medications such as Fentanyl in their formulary. Because Fentanyl is an opiate, it falls within the category of controlled substances.  In addition to restricting coverage of Fentanyl to approved use for cancer patients in the treatment of break-through pain, Medicare plans providing prescription drug benefits are likely to have other restrictions, such as:

  1. Prior authorization rules, under which a doctor must submit a request that the plan cover Fentanyl and provide the medical reason for use of the medication
  2. Limits on the amountof Fentanyl the plan will cover at one time
  3. Step therapy, which restricts coverage for Fentanyl to circumstances in which other medications to control pain in cancer treatment have not been successful.

Where do I find details about Fentanyl in Medicare Part D Prescription Drug Plan’s formulary?

You can review your plan’s formulary on its website or contact the plan’s customer service department for assistance.  If you intend to enroll in a Medicare Part D Prescription Drug Plan or a Medicare Advantage Prescription Drug plan, you can review different plans’ formularies by using the online Medicare Plan Finder tool on Medicare’s website. The tool will show you which drugs are covered by each plan, if there are any utilization management requirements, and the cost-sharing amounts. The tool includes links to the plans’ websites.

Do you have questions about your current Medicare Part D coverage for Fentanyl, or the plan you are considering? I can help you evaluate the different plan options available to you.

To get some more Medicare plan information to review, use the links below; you can schedule a phone call with me or have me email you plan options available through eHealth.

If you’d like to compare some of the Medicare plans that could cover your medications, use the Compare Plans buttons on this page.

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