Alternatives to PAIN Act
Summary
What This Bill Does
The Alternatives to PAIN Act changes Medicare Part D coverage for qualifying non-opioid pain management drugs beginning with plan years on or after January 1, 2026. A qualifying drug or biological product must be FDA-approved to reduce postoperative pain or another form of acute pain and must be non-opioid under the statutory definition. Part D deductibles cannot apply to those drugs, and plans must place them on the lowest cost-sharing tier if the plan uses tiers. Prescription drug plans and MA-PD plans also may not impose step therapy requiring an enrollee to use an opioid before receiving the non-opioid drug, and may not impose prior authorization on a covered qualifying non-opioid pain management drug.
Who Benefits and How
Medicare Part D enrollees with acute pain benefit from lower out-of-pocket costs for qualifying non-opioid pain drugs. Patients avoiding opioids benefit because plans cannot require opioid-first step therapy before covering a qualifying non-opioid drug. Non-opioid pain drug manufacturers benefit from preferred Part D cost-sharing and fewer utilization-management barriers. Clinicians treating postoperative pain benefit from easier access to non-opioid options for Medicare patients.
Who Bears the Burden and How
Part D prescription drug plans must waive deductibles, use the lowest cost-sharing tier, and remove prior authorization for qualifying drugs. MA-PD plans must eliminate opioid-first step therapy and prior authorization for covered qualifying non-opioid pain drugs. Federal Medicare spending may rise if more qualifying non-opioid drugs are covered with lower patient cost-sharing. Plan formulary managers lose utilization-management tools for the covered non-opioid pain drugs.
Key Provisions
- Requires qualifying non-opioid pain management drugs to avoid the Part D deductible.
- Requires qualifying drugs to be placed on the lowest cost-sharing tier for plan years beginning in 2026.
- Prohibits opioid-first step therapy for qualifying non-opioid pain management drugs.
- Prohibits prior authorization for covered qualifying non-opioid pain management drugs.
Evidence Chain:
This summary is generated from the full bill text using AI analysis. Expand "Detailed Analysis" below for identified beneficiaries/burden bearers with clause-level evidence links.
At a Glance
What This Bill Does
Requires Medicare Part D plans to place qualifying non-opioid pain management drugs on the lowest cost-sharing tier, waive the deductible, and avoid opioid-first step therapy or prior authorization.
Key Policy Areas
Health Care, Medicare, Opioids
Primary Purpose
Requires Medicare Part D plans to place qualifying non-opioid pain management drugs on the lowest cost-sharing tier, waive the deductible, and avoid opioid-first step therapy or prior authorization.
Policy Domains
Resolution provisions
Identified Gains
- Medicare Part D enrollees
- Patients avoiding opioids
- Non-opioid pain drug manufacturers
- Clinicians treating postoperative pain
Identified Costs
- Part D prescription drug plans
- MA-PD plans
- Federal Medicare budget
- Plan formulary managers
Sponsors
Legislative Progress
In CommitteeMrs. Miller-Meeks (for herself, Ms. Barragán, Mr. Kelly of Pennsylvania, …
Referred to the Committee on Energy and Commerce, and in …
Introduced in House
Stakeholder Effects
cui bono?How this legislation distributes effects. Mention counts reflect frequency, not effect magnitude.
Bill Structure & Actor Mappings
Who is "The Secretary" in each section?
We use a combination of our own taxonomy and classification in addition to large language models to assess meaning and potential beneficiaries. High confidence means strong textual evidence. Always verify with the original bill text.
Learn more about our methodology