Will Medicare Cover Pain Medication?

Doctors prescribe pain medications for a number of reasons. s. A doctor may give you pain medication after surgery or a serious injury. Some people need long-term therapy with prescription pain medication to manage a chronic condition such as fibromyalgia or arthritis. 

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It’s helpful to know when and how Medicare covers pain medication and other methods of pain control such as acupuncture and chiropractic care in the event you need it.

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How Medicare covers pain medication

Each part of Medicare covers different aspects of pain management. Medicare Part A, Part B, and Part D all can cover pain medication in different scenarios. However, most of the time, your Medicare Part D plan pays for your pain medication. 

Medicare Part D pain medication coverage

Medicare Part D plans are offered by private insurance companies. However, Medicare has specific guidelines all Part D plans must follow in order for them to be approved for sale.

For example, all Part D plans have a formulary. A formulary is the list of medications covered by the plan. All formularies must include at least two medication options from the most popular prescription classes, and all medications in certain classes including antidepressants, immunosuppressants, and anticancer drugs

While the requirement is only two drugs per class, most Part D plans cover many more drugs, giving you and your doctor more options to choose from. Most Part D plans cover most of the most commonly prescribed opioid pain medications, such as fentanyl, hydrocodone, and oxycodone. 

If your Medicare Part D plan includes your pain medication on its formulary, your plan will help cover part of the cost of that drug. You may have to pay full price for the medication until you meet your deductible, but after that, you will only be responsible for a copay or coinsurance. However, if your plan doesn’t include that specific pain medication on its formulary, you’ll be responsible for the full retail cost of the drug unless you qualify for a formulary exception.

Medicare Part A and Part B pain medication coverage

Medicare Part A and Part B provide inpatient and outpatient coverage. If you’re admitted to a hospital or other inpatient facility and receive pain medication during your admission, Medicare Part A will likely cover it. However, if you are under observation at the emergency room, and therefore not formally admitted, Medicare Part B will cover any pain medication you receive.

In these scenarios, you may be responsible for both Part A and Part B deductibles as well as the Part B coinsurance. Medicare Part D generally only covers medications you fill at the pharmacy and administer yourself. 

Medicare Part D pain medication restrictions

Medicare Part D plans may have certain restrictions such as prior authorization or quantity limits on specific drugs listed on their formulary. When you fill an opioid pain medication at the pharmacy, the pharmacist may perform a safety review to ensure it is being used safely.

If your pharmacist suspects misuse after the safety review is done, he may speak with your doctor before filling the prescription. You may need to get prior authorization from your plan for certain pain medications.

Quantity limits are also typical with many pain medications. If your pain medication has a quantity limit restriction, that simply means you are only allowed to get a specific number of pills each month. If your doctor prescribes more than the allowed doses, your doctor may have to request an exception with your Part D plan before it covers your pain medication. 

Other pain management Medicare services

Medicare Part B covers a variety of pain management outpatient services that can be an alternative to pain medication. Medicare may cover pain management services such as physical and occupational therapy, and some chiropractic services, and acupuncture at 80%.

Part B will cover physical and occupational therapy up to a specific soft limit. However, as long as it continues to be medically necessary, Part B will continue to pay for it. Part B also covers manual manipulation of the spine by a chiropractor to correct a subluxation. Other services provided by the chiropractor are generally not covered.

Recently, Part B started covering acupuncture, but only for a specific purpose – to treat chronic lower back pain. Part B will cover up to 12 acupuncture sessions within three months. Part B may cover additional sessions if your lower back pain improves from the previous sessions. 

Drug management programs

Medicare Part B and Part D also cover some programs that can help manage your opioid use. Medicare Part B covers depression screenings, alcohol and drug misuse counseling, and individual and group therapy. Medicare Part D plans also have drug management programs. 

Pain medications are usually an essential part of pain management. However, you should always practice safe use of opioid pain medications. If possible, discuss with your doctor about non-opioid pain medications or alternative pain management services, as Medicare also covers those.

Peter Simpson

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