Does Medicare Cover Lyrica?

Medicare Benefits Solutions
Aug 25, 2021

Does Medicare Cover Lyrica? If you suffer from nerve pain, you may be familiar with Lyrica. The generic form of Lyrica is pregabalin, available in capsule form and as an oral solution. According to its manufacturer, a Pfizer division, Lyrica is a prescription drug for adults that is designed to treat pain from:

• Damaged nerves associated with diabetes, shingles or a spinal cord injury
• Fibromyalgia, which affects nerves throughout your body

Lyrica falls into the category of antiepileptic drugs and is also prescribed to epilepsy patients as a treatment for seizures. It can be prescribed to children as young as one month.

To get prescription drug benefits through your Medicare coverage, you need to have Part D.

Part D formulary

To check if you have Medicare coverage for Lyrica or pregabalin, take a look at your drug plan’s formulary. This is a list of drugs your plan has selected for coverage. Drugs in the formulary are deemed to be medically necessary to treat certain conditions and must be approved by the U.S. Food and Drug Administration (FDA). The FDA approved pregabalin in 2019. 

A formulary is generally made up of tiers structured around types of drugs, including preferred and non-preferred, generic and brand-name, and specialty drugs. You will likely find Lyrica under the tier for preferred brands, which are typically cost-effective brand-name drugs.

Check your benefits summary, or contact your plan administrator, to find out the requirements, limits, and copays. For example, some plans require prior authorization. Mail-order delivery, if that is an option, can save you money.

Part D Medicare insurance

If you are newly eligible for Medicare coverage, sign up for a Medicare-approved drug plan during your Initial Enrollment Period. Unless you have a creditable prescription drug plan, you may incur a late enrollment penalty if you delay enrollment and decide to sign up later. The penalty is a higher premium that continues as long as you have Part D. 

For a plan to be creditable, it has to offer the same or higher coverage than you would get with a Medicare drug plan. If you have group health insurance with prescription drug coverage through your employer or union, you may be eligible for a Special Enrollment Period. 

To get a Medicare insurance drug plan, choose one of these options:

• Join a stand-alone plan, which adds drug coverage to Original Medicare insurance.
• Sign up for a Medicare Advantage Prescription Drug (MAPD) plan that bundles Part A and Part B with prescription drug coverage.

Medicare Supplement plans, also known as Medigap, do not cover prescription drugs.

Resources

Pfizer provides online access to manufacturer details about Lyrica indications, contraindications, usage, and precautions. Visit Pfizer’s website to learn more.