Medicare plans would limit patient costs for certain non-opioid medicines

Medicare drug plans would waive the deductible and use their lowest patient payment tier, if they have tiers, for eligible covered medicines. These rules cover Medicare Part D medicines, including coverage for people receiving low-income assistance. Eligible medicines must have FDA approval for acute pain, avoid acting on opioid receptors, and have no FDA-rated equivalent sold in the United States. Their monthly wholesale price must not exceed the federal threshold for specialty-tier drugs. The rules would apply to plan years beginning on or after January 1, 2026.

Medicare drug plans would not require advance approval or make patients try an opioid before receiving an eligible covered medicine. The restrictions would apply to eligible medicines already covered by stand-alone Medicare drug plans or Medicare Advantage drug plans. Eligible medicines must have FDA approval for acute pain, avoid acting on opioid receptors, and have no FDA-rated equivalent sold in the United States. Their monthly wholesale price must stay within the federal specialty-tier threshold. The ban on trying another medicine first applies only when that medicine is an opioid.