Sponsors (37)
The bill improves access to and affordability of certain non-opioid pain treatments for Medicare enrollees and reduces opioid exposure, but shifts costs and clinical oversight burdens onto plans, taxpayers, and potentially some patients, risking higher overall drug spending and coverage gaps for certain products.
Medicare beneficiaries will pay less out-of-pocket for qualifying non-opioid acute/postoperative pain drugs because the Part D deductible is waived starting in 2026.
Low-income Part D enrollees will face lower cost barriers for qualifying non-opioid pain drugs because they receive the same deductible waiver and the lowest cost-sharing tier.
Medicare patients will get faster access to qualifying non-opioid pain treatments because plans cannot require trying an opioid first (no step therapy).
Taxpayers and Medicare beneficiaries could face higher overall drug spending if qualifying non-opioid drugs are more expensive and utilization controls are restricted.
Insurers and Part D plans lose utilization-management tools (step therapy, prior authorization), which could force plans to raise premiums, increase cost-sharing elsewhere, or reduce other benefits to control costs.
Removing prior authorization may increase the use of some non-opioid drugs that carry safety risks or harmful interactions, creating clinical oversight concerns for patients with complex conditions.
Based on analysis of 3 sections of legislative text.
From Jan 1, 2026, Medicare plans must waive deductibles and place certain qualifying non‑opioid acute pain drugs on the lowest cost tier and cannot require opioid‑first or prior authorization for them.
Requires Medicare Part D and Medicare Advantage prescription drug plans (for plan years starting Jan 1, 2026) to make certain FDA‑labeled non‑opioid drugs for acute/postoperative pain easier and cheaper to get. These drugs would have the Part D deductible waived, be placed on the lowest cost‑sharing tier available, and plans could not force patients to try an opioid first or require prior authorization for them. Also applies the same deductible/tier treatment to low‑income subsidy beneficiaries and adds statutory definitions and a price cap test so only qualifying non‑opioid pain drugs that meet FDA labeling, lack a U.S. therapeutic equivalent, and fall under a specialty-tier monthly cost threshold are covered by these rules.
Introduced February 6, 2025 by Thomas Roland Tillis · Last progress February 6, 2025