Sponsors (37)
The bill improves access to and affordability of certain non-opioid pain medications for Medicare enrollees and reduces opioid exposure, but does so at the risk of higher program and premium costs and reduced payer oversight that could raise safety and cost-shifting concerns.
Medicare beneficiaries will pay less out-of-pocket for qualifying non-opioid acute/postoperative pain drugs because the Part D deductible is waived beginning in 2026.
Low-income Part D enrollees will face lower cost sharing (lowest tier) for qualifying drugs, reducing financial barriers to pain treatment.
Medicare patients will get faster access to qualifying non-opioid pain drugs because plans cannot require trying an opioid first and cannot impose prior authorization for those drugs, reducing administrative delays and denials.
Medicare program spending and taxpayer exposure could rise because utilization controls are limited and deductible/cost-sharing protections increase drug use and program payments.
Insurers and Part D plans may respond by raising premiums or reducing other benefits to offset higher drug costs, which could increase costs for beneficiaries and taxpayers.
Removing prior authorization and step-therapy safeguards could increase use of some non-opioid drugs that have safety risks or clinically significant interactions, because less clinical oversight is required.
Based on analysis of 3 sections of legislative text.
Waives Part D deductible, places qualifying non‑opioid pain drugs on the lowest tier, and bans opioid‑first step therapy and prior authorization for those drugs starting plan years on/after Jan 1, 2026.
Official title: Amend title XVIII of the Social Security Act to ensure appropriate access to non-opioid pain management drugs under part D of the Medicare program.
Introduced February 6, 2025 by Thomas Roland Tillis · Last progress February 6, 2025
Requires Medicare Part D and Medicare Advantage prescription drug plans, starting for plan years on or after January 1, 2026, to waive the Part D deductible and place certain FDA‑labeled non‑opioid pain management drugs on the lowest cost‑sharing tier when the drug meets specified criteria. Also bars plans from using step therapy that forces patients to try opioids first and from requiring prior authorization for these qualifying non‑opioid pain drugs, and sets a price cap test tied to a specialty‑tier monthly cost threshold set by the Secretary.