Medicare's Coverage of Butorphanol
Medicare Part D covers butorphanol, a prescription opioid painkiller, but only if your plan includes it on its formulary — the list of drugs each plan covers. Not every Part D plan covers butorphanol, and the ones that do may require you to meet conditions before they will pay for it, such as trying a different painkiller first or getting approval from your doctor's office in advance.
Butorphanol is a mixed opioid agonist-antagonist, meaning it works differently from standard opioids like morphine or oxycodone. It is often prescribed for moderate to severe pain, migraine headaches, or post-operative pain. Because it carries abuse risk like other opioids, Medicare and individual plans place restrictions on how and when it is covered.
The coverage rules depend on which Part D plan you are enrolled in and whether you are in Original Medicare or a Medicare Advantage plan. Both types of plans can cover butorphanol, but the details — what you pay, what hoops you jump through — vary by plan and by year.
Key Takeaways
- Your Part D plan's formulary determines whether butorphanol is covered at all; you can check your plan's formulary on Medicare.gov or by calling the plan directly.
- Many plans place butorphanol in a higher cost tier, meaning you pay more out of pocket than you would for other painkillers.
- Your plan may require prior authorization, meaning your doctor must get approval before the pharmacy will fill the prescription.
- If your plan does not cover butorphanol or the cost is too high, you can switch to a different Part D plan during the annual enrollment period in October and November.
How to Check if Your Plan Covers Butorphanol
The fastest way to find out is to call your Part D plan directly. Have your member ID card ready. Tell them you want to know if butorphanol is on the formulary, what tier it is in (which determines your copay), and whether prior authorization is required. This takes five minutes and gives you a definitive answer.
You can also check online. Go to Medicare.gov, select "Find Care Providers and Suppliers," then search for your plan by name. Most plans post their formularies as downloadable PDFs. Search the document for "butorphanol" to see the tier and any restrictions. If you do not see the drug listed, it is not covered by that plan.
If you are in a Medicare Advantage plan rather than Original Medicare plus Part D, call your plan's customer service line. Medicare Advantage plans have their own drug coverage rules and formularies, which differ from Part D plans.
What Prior Authorization Means and How Long It Takes
Prior authorization is a requirement that your doctor's office contact your insurance plan before you fill the prescription. The plan reviews your medical history and the reason for the prescription, then either approves or denies it. If approved, the pharmacy can fill it. If denied, you and your doctor have to decide on a different approach.
Prior authorization for butorphanol typically takes one to three business days. Your doctor's office handles the request — you do not call the plan yourself. However, you should tell your doctor's office that you need this done quickly, especially if you are in pain and waiting for relief. Some offices batch these requests and send them once a day, which can add delay.
If the plan denies prior authorization, you have the right to ask for a review. Your doctor can appeal the decision by providing additional medical information explaining why butorphanol is necessary for your case. This appeal process can take up to 72 hours.
Cost Tiers and What You Will Pay
Part D plans organize drugs into tiers, usually four or five levels. Each tier has a different copay or coinsurance amount. Butorphanol is often placed in Tier 3 or Tier 4, which are higher tiers, meaning your out-of-pocket cost is higher than for drugs in Tier 1 or Tier 2.
A typical copay structure might look like this: Tier 1 costs $5 to $10, Tier 2 costs $15 to $25, Tier 3 costs $35 to $50, and Tier 4 costs $60 or more. Some plans use coinsurance instead, meaning you pay a percentage of the drug's cost rather than a flat copay. Your plan's summary of benefits will show exactly what you pay for butorphanol.
Once you reach the coverage gap (the "donut hole"), your costs change again. In 2024, the gap begins after you and your plan have spent $5,850 combined on covered drugs. During the gap, you pay a higher percentage of the drug cost until you reach catastrophic coverage. Your plan's materials explain these thresholds for the current year.
What to Do if Your Plan Does Not Cover Butorphanol
If butorphanol is not on your plan's formulary or the cost is unaffordable, you have several options. First, ask your doctor whether a different painkiller might work. Many plans cover other opioids or non-opioid alternatives at lower cost tiers. Your doctor knows your medical history and can advise whether a substitute is safe for you.
Second, you can request a formulary exception. This is a formal request to your plan asking them to cover a drug that is not on the formulary or to move it to a lower tier. Your doctor must submit this request and explain the medical reason why butorphanol is necessary and why alternatives will not work. The plan has 72 hours to respond. Some plans grant exceptions; others deny them. There is no may provide, but it is worth trying if butorphanol is truly the right drug for you.
Third, you can switch to a different Part D plan. During the annual enrollment period from October 15 to December 7 each year, you can change plans without penalty. Compare the formularies of other plans to find one that covers butorphanol at a cost you can manage. Medicare.gov has a plan comparison tool that shows drug coverage side by side.
Butorphanol and the Opioid Safety Rules
Medicare and Part D plans monitor opioid prescriptions closely. If you are taking butorphanol, your doctor may be required to check your prescription history through a state database called the Prescription Drug Monitoring Program (PDMP) to make sure you are not receiving opioids from multiple doctors. This is a safety measure, not a barrier to coverage, but it means your doctor's office will need to do this check before refilling your prescription.
Some plans also require that you sign an opioid agreement with your doctor, acknowledging that you understand the risks of opioid use and agree to use the drug only as prescribed. This is a one-time document, not something you repeat with every refill.
If you are taking other medications that interact with opioids — such as benzodiazepines or certain sleep aids — your pharmacist or doctor may flag a safety concern. This does not automatically mean you cannot take butorphanol, but your doctor may need to adjust your other medications or monitor you more closely.
Frequently Asked Questions
Can I get butorphanol covered if I am in Original Medicare without Part D?
No. Original Medicare does not cover outpatient prescription drugs. You must have Part D coverage to have butorphanol covered. If you do not have Part D, you can enroll during the annual enrollment period or during a special enrollment period if you have a may have access to life event.
Does Medicare Advantage cover butorphanol?
Most Medicare Advantage plans include prescription drug coverage and may cover butorphanol, but the formulary and cost vary by plan. Call your plan to check. If your plan does not cover it, you can switch to a different Medicare Advantage plan or to Original Medicare plus Part D during the annual enrollment period.
What if my doctor prescribes butorphanol but my plan denies prior authorization?
You can ask your doctor to appeal the denial by submitting additional medical information to the plan. You also have the right to request an independent review by an outside party. Your plan's customer service line can explain the appeal process and timeline.
Will switching Part D plans in the middle of the year affect my butorphanol prescription?
You can only switch Part D plans during the annual enrollment period in October and November, or if you have a may have access to life event such as loss of other coverage. If you switch, your new plan's formulary takes effect on January 1. Your current plan will continue to cover butorphanol through December 31.
Is butorphanol cheaper if I pay cash instead of using insurance?
Sometimes. If your copay is very high, a cash price from a pharmacy or a discount program like GoodRx may be lower. Ask your pharmacist for the cash price and compare it to your copay. However, cash payments do not count toward your Part D out-of-pocket spending, so they do not help you reach catastrophic coverage faster.