Does Medicare Cover Prescription Painkillers?
This article was updated on: 09/10/2018
What are prescription painkillers?
Prescription painkillers, also known as opioids or narcotics, are powerful pain-reducing medications, according to the Food and Drug and Administration (FDA). Narcotics work by binding to receptors in the brain, which blocks the feeling of pain, according to the U.S. National Library of Medicine. According to the Drug Enforcement Administration (DEA) examples of opioid painkillers include:
- Oxycodone (brand name: OxyContin)
- Hydrocodone bitartrate/acetaminophen (brand name: Vicodin)
According to the Centers for Disease Control and Prevention (CDC), older adults age 40 and up are more likely than younger adults to use prescription opioids. This may be because older adults are more likely to have developed a serious health condition, such as cancer, that a doctor determined requires prescription pain relief.
Opioid pain relievers are relatively safe when taken for a short time as prescribed by a doctor, according to the National Institute of Drug Abuse (NIDA), but prescription painkillers may be misused for the sense of euphoria they produce as well as pain relief. When misused or abused opioids may cause serious harm, addiction and even death, according to the FDA. Prescription painkillers can be habit-forming and the U.S. National Library of Medicine (NLM) recommends that you shouldn’t take narcotic prescription painkillers for more than 3 to 4 months unless you are under the direct care of a doctor.
According to the Drug Enforcement Administration, opioids and prescription painkillers are controlled substances that vary on classification depending on their medical usefulness, abuse potential, safety, and drug dependence profile.
How do I get Medicare coverage for prescription painkillers?
Medicare Part A may cover prescription painkillers you receive as a hospital inpatient, but generally Medicare Part A and Part B don’t cover prescription drugs you take at home. There are two main ways to get coverage for prescription painkillers under the Medicare Part D program:
- You can enroll in a stand-alone Medicare Part D Prescription Drug Plan to complement your Original Medicare (Part A and Part B) benefits.
- You can enroll in a Medicare Advantage Prescription Drug plan, such as a Medicare Health Maintenance Organization (HMO) plan or a Preferred Provider Organization (PPO) plan.* You must continue to pay your Part B premium, plus any additional monthly premium required by your plan when you enroll in Medicare Advantage.
The plan options described above are available from private, Medicare-approved insurance companies. Not every plan type and optional benefit is available in every location, and plan benefits and premiums may vary depending on where you live.
Also keep in mind that not all plans cover the same set of prescription drugs. Every private insurance company contracted with Medicare to provide prescription drug coverage maintains its own formulary, which is a list of covered medications. If you have a prescription for a specific painkiller, you may want to check the formularies of the plans you’re considering to make sure it’s covered. Note that plans may change their formularies from time to time, but you will receive notice from your plan when necessary.
Please also note that deductibles, coinsurance amounts, and copayments may vary among plans.
When can I apply for Medicare coverage for prescription painkillers?
Generally, an ideal time to sign up for a Medicare plan that includes prescription drug coverage for prescription painkillers is when you’re first eligible for Medicare – during your Initial Enrollment Period. Although prescription drug coverage is optional, if you wait to enroll, you could face a late-enrollment penalty if you decide to enroll later on. Read about the other times you can sign up for a Medicare plan.
If you have other questions about Medicare prescription drug coverage for painkillers, I’d be happy to help. To set up a time to talk one-on-one about your Medicare needs, click the link below. You can also request an email from me with personalized Medicare information; you’ll find that link below as well. To start browsing on your own, click the Compare Plans button on this page.
*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.