Does Medicare cover Lyrica?

Medicare provides cover for Lyrica, also known by its generic name pregabalin, when a person has a plan that includes prescription drug benefits.

Medicare parts A and B cover limited take-home prescription medications.

Medicare Part D prescription drug plans and most Medicare Advantage plans tend to cover Lyrica. The cost depends on the plan’s formulary, deductible, and copayments.

This article looks at why a doctor may prescribe Lyrica, its generic alternative, and how Medicare covers prescription drugs.

We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:

·        Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.

·        Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.

·        Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.

What does Lyrica treat?

Lyrica received Food and Drug Administration (FDA) approval in 2004 for the treatment of nerve pain.

People may have nerve pain with:

·        diabetes

·        spinal cord injury

·        shingles

·        fibromyalgia

Special information

It is important to note that the medication has a significant number of drug interactions.

Lyrica can also cause a severe allergic reaction. With allergic reactions, people may develop hives, difficulty breathing, or swelling around the throat, mouth, and face.

Unless there is a severe allergic reaction, a person should not stop taking the drug suddenly, as they may experience withdrawal symptoms.

Which Medicare parts cover Lyrica?

There are several parts to Medicare, and each offers different benefits.

Original Medicare

Original Medicare has two parts: Part A and Part B.

Medicare Part A provides inpatient benefits for:

·        inpatient hospital care

·        stays at a skilled nursing facility

·        hospice care

Medicare Part B covers:

·        outpatient appointments

·        diagnostic tests

·        outpatient treatment

·        preventive services, such as flu shots and cancer screenings

Part B covers limited prescription medications that a person receives in a doctor’s office or at an outpatient facility.

Medicare parts A and B do not cover Lyrica.

Medicare Advantage

Medicare Advantage, or Medicare Part C, plans combine Medicare parts A and B benefits and often include additional coverage, such as vision and hearing care.

According to the Kaiser Family Foundation, around 89% of all Medicare Advantage plans available in 2021 will include prescription drug coverage.

If a Medicare Advantage plan covers prescription medications, it will often cover Lyrica and its generic alternative.

Part D

Medicare Part D prescription drug plans cover take-home medications that a doctor has prescribed.

People with Medicare Advantage plans that have drug coverage cannot also enroll in a prescription drug plan.

When a Medicare Advantage plan does not include cover for medication, a person may only purchase a prescription drug plan if they have one of the following plans:

·        a Private Fee-for-Service plan

·        a Medicare savings account

·        a Medicare cost plan

Private insurance companies administer Medicare parts C and D. These companies must follow Medicare rules and be approved to sell policies.

Formularies

Private insurers maintain a list of covered prescription drugs called a formulary.

The formulary contains covered brand-name and generic drugs, and Medicare requires each formulary to have at least two drugs in the most commonly prescribed categories and classes.

Many plans also use a tier system in their list of covered drugs. Typically, generic drugs are in the lower tiers and, therefore, cost less.

Plans providers can choose which drugs they will offer, meaning that a formulary may not include the specific drug a person needs.

If a plan formulary does not include pregabalin or Lyrica, a person can request an exception, as drug plans can make changes to their formulary list during the year.

Generic vs. brand-name drugs

In July 2019, the FDA approved nine drug companies to produce generic versions of Lyrica. There are now capsule options and a liquid version available.

The FDA require generic drugs to have the same active ingredients as brand-name drugs, and the manufacturers must prove that the product works in the same way as the brand-name version.

However, generic drugs can have different inactive ingredients, which may cause side effects in some people.

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Costs

There is a large cost difference between brand-name Lyrica and generic pregabalin. There are a range of prices that people can expect to pay at different pharmacies.

These prices are listed for cash customers and are the lowest in the range of prices. The price a person pays with Medicare Part D depends on the plan’s formulary and copayment structure.

90 pills	Lyrica	Generic
25 milligrams (mg)	$735.07	$18.84
50 mg	$735.07	$20.97
75 mg	$735.07	$18.34
100 mg	$735.07	$20.63
150 mg	$735.07	$19.43
200 mg	$735.07	$25.02
225 mg	$735.07	$24.68
300 mg	$735.07	$26.92

Help with costs

There are several steps that a person can take to ensure that they are getting the best price for their medication. These include:

·        considering using a generic drug in place of Lyrica

·        considering a mail-order pharmacy

·        looking for a plan with lower drug costs by using the Medicare Plan Finder to compare plan options

·        considering using national or community organizations that help pay drug costs

·        applying for the State Pharmaceutical Assistance Program

If a person needs additional support in paying for prescription costs due to having limited income and resources, they can apply for some other programs. These include:

Medicaid

Medicaid is a federal and state program for people with limited income and resources. It can help with medical costs, including prescriptions.

Medicare savings programs

Medicare savings programs can help people pay plan premiums, deductibles, copayments. Help with prescription drug costs is also available.

Program of All-Inclusive Care for the Elderly

The Program of All-Inclusive Care for the Elderly is a state-run community program, meaning that individuals can stay at their home and receive the healthcare they need.

The program may also include help to cover prescription medications.

Extra Help

The Extra Help program helps people pay prescription drug costs, including Medicare Part D premiums, deductibles, and copayments.

Supplemental Security Income

Supplemental Security Income (SSI) is a monthly cash benefit paid by the Social Security Administration. It is not the same as Social Security retirement benefits.

Summary

Medicare Advantage and Medicare Part D may cover Lyrica or a generic substitute if the drug appears on the plan provider’s formulary.

The private insurers who administer the plans will determine the drugs included on their formulary. A formulary is a list of covered medications.

In 2019, generic versions of Lyrica became available. The price difference between generic pregabalin and brand-name Lyrica is significant.

There are several help options available for prescription drug costs, including state and local charity programs, state and drug company programs, and programs such as Medicaid, Extra Help, and SSI.

The information on this website may assist you in making personal decisions about insurance, but it is not intended to provide advice regarding the purchase or use of any insurance or insurance products. Healthline Media does not transact the business of insurance in any manner and is not licensed as an insurance company or producer in any U.S. jurisdiction. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance.

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