Skip to content
Congress·In Committee·about 1 year ago

Congress Targets Lower Medicare Part D Costs and Fewer Barriers for Certain Non-Opioid Pain Drugs

Also known as: Alternatives to PAIN Act

Legislative Progress

✓ Filed
Review
House
Senate
President

Impacts

Mixed Impacts(1)
Mental Health
Neutral
Positive Impacts(2)
Medicare
Helps
Chronic Illness
Helps

Key Points

  • Starting in 2026, Medicare Part D plans would have to cover certain non-opioid pain drugs with no deductible and the lowest cost-sharing tier.
  • The bill targets drugs used for post-surgery or other acute pain that do not work on opioid receptors, aiming to make non-opioid options easier to get.
  • It mainly applies to newer drugs with no therapeutically equivalent version sold in the U.S., and only if the monthly price stays under Medicare’s specialty-tier threshold.
  • Part D plans could not require “step therapy” that makes a patient try an opioid first before getting the non-opioid drug.
  • Part D plans also could not require prior authorization for these qualifying non-opioid pain drugs, which could speed up access at the pharmacy.
HealthcareMedicare MedicaidPrescription DrugsDrug Policy

Milestones

2 milestones2 actions
Feb 12, 2025House

Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.

Feb 12, 2025

Introduced in House

What Happens Next

Projected impacts based on AI analysis

2026-01-01

Medicare Part D plans must treat qualifying non-opioid pain drugs as no-deductible drugs.

If you’re prescribed one of these qualifying drugs, the plan can’t make you “pay the deductible first” for that medicine starting with 2026 coverage.

2026-01-01

Qualifying non-opioid pain drugs must be placed on the plan’s lowest cost-sharing tier (if the plan uses tiers).

Your copay/coinsurance for these drugs should be closer to the cheapest covered drugs on your plan, not specialty or high tiers, starting in 2026.

2026-01-01

Plans are prohibited from requiring an opioid first (step therapy) for qualifying non-opioid pain drugs.

If your doctor prescribes a qualifying non-opioid drug, the plan can’t tell you to try an opioid before it will cover the non-opioid option starting in 2026.

2026-01-01

Plans are prohibited from using prior authorization for qualifying non-opioid pain drugs.

You should face fewer delays and less paperwork waiting for plan approval before the pharmacy can fill a qualifying drug starting in 2026.

During preparation for the 2026 plan year

Plans update their formularies, pharmacy systems, and member materials to reflect the new rules for 2026 coverage.

During the 2026 plan year rollout, you may see changes in drug lists and copays; it may be easier to confirm at the pharmacy whether a drug meets the “qualifying” definition.

Related News

1 article
GlobeNewswire·5 months ago

Lexicon Pharmaceuticals Convenes Roundtable to Address Public Policy Gaps for People with Chronic Pain

Company roundtable discusses the Alternatives to PAIN Act’s Medicare Part D access provisions for non-opioid pain treatments and argues the bill should be expanded beyond acute/post-surgical pain to include chronic pain.

+

Source Information

Document Type

Congressional Bill

Official Title

Alternatives to PAIN Act

Bill NumberHR 1227
Congress119th Congress
ChamberHouse of Representatives
Latest ActionReferred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.

Sponsor

Cosponsors

(76)
D: 38R: 38

Analysis generated by AI. While we strive for accuracy, this should not be considered legal or professional advice. Always verify information with official government sources.