Medicare coverage for levorphanol depends on which part of Medicare you have and where you fill the prescription
Levorphanol is an opioid pain medication used to treat moderate to severe pain. Whether Medicare covers it depends on whether you have Part B (medical insurance), Part D (prescription drug coverage), or a Medicare Advantage plan. Most people with Medicare can get levorphanol covered, but the amount you pay out of pocket varies based on your plan and which pharmacy you use.
If your doctor prescribes levorphanol as an injection or infusion given in a hospital or clinic, Medicare Part B typically covers it. If you fill a levorphanol prescription at a pharmacy, you need Part D or a Medicare Advantage plan that includes drug coverage. The drug itself is not on any Medicare exclusion list, meaning there is no blanket ban against covering it.
Key Takeaways
- Levorphanol injections or infusions given in a medical setting are covered under Medicare Part B, though you pay your coinsurance or copay.
- Levorphanol tablets or liquid filled at a pharmacy require Part D or a Medicare Advantage drug plan to be covered.
- Your out-of-pocket cost depends on your specific plan's formulary, deductible, and which pharmacy tier the drug is on.
- You can call your plan directly or check your plan's formulary online to confirm coverage before your doctor writes the prescription.
How Medicare Part B covers levorphanol in medical settings
When levorphanol is given to you as an injection or infusion in a hospital, outpatient clinic, or doctor's office, Medicare Part B covers the drug itself. You pay 20 percent coinsurance after you meet your Part B deductible (which is $240 in 2024, though this amount changes yearly). The facility or provider bills Medicare directly for the medication and the administration.
This applies whether the levorphanol is given for acute pain after surgery, chronic pain management in a clinic setting, or palliative care. The key is that a healthcare provider administers it to you in person. If you receive it at home through a home health agency, Part B may cover it as part of your home health benefit, but the rules are more complex — ask your home health provider to verify coverage before starting.
How Medicare Part D covers levorphanol at the pharmacy
If your doctor prescribes levorphanol tablets or liquid that you pick up at a pharmacy, you need Medicare Part D or a Medicare Advantage plan with prescription drug coverage. Part D is the add-on drug plan you can buy if you have Original Medicare (Part A and Part B). Most Medicare Advantage plans include drug coverage automatically.
Levorphanol is not a controlled substance that Medicare refuses to cover, but it is an opioid, so some plans may place it on a higher tier or require prior authorization from your doctor before they will pay for it. Check your plan's formulary — the official list of covered drugs — before filling the prescription. You can find your plan's formulary on its website or by calling the plan's customer service number, which is on your insurance card.
What you pay depends on your plan and pharmacy
Your out-of-pocket cost for levorphanol at the pharmacy varies based on your Part D plan's structure. Most plans charge a copay (a flat dollar amount per prescription) or coinsurance (a percentage of the drug's cost). Some plans have a deductible you must meet before coverage kicks in. Levorphanol is a brand-name opioid, so it may cost more than generic pain medications, and your plan may place it on a higher tier.
The pharmacy you use also affects your cost. Each Part D plan has a network of preferred pharmacies where your copay is lower. Using an out-of-network pharmacy costs more. If levorphanol is expensive at your preferred pharmacy, ask your pharmacist whether a different network pharmacy in your area has a lower price, or ask your doctor whether a generic opioid like morphine or hydromorphone might work for you and cost less.
Prior authorization and step therapy requirements
Some Medicare Part D plans require prior authorization before they will cover levorphanol. This means your doctor must contact the plan and explain why levorphanol is medically necessary before you fill the prescription. The plan then approves or denies the request, usually within 24 to 72 hours. If your plan requires it, your doctor's office typically handles this step, but it is worth asking your doctor's staff to confirm they will submit the request.
A few plans use step therapy, which means you may have to try a cheaper opioid first and show that it did not work before the plan will cover levorphanol. This is less common for opioids than for other drug classes, but it is possible. If your plan has this requirement and your doctor believes levorphanol is the right choice from the start, your doctor can request an exception. Ask your plan's customer service whether step therapy applies to levorphanol on your plan.
How to confirm coverage before your prescription is filled
The fastest way to know whether your plan covers levorphanol is to call your Part D or Medicare Advantage plan's customer service number. Have your plan member ID ready (it is on your insurance card). Tell them you want to know whether levorphanol is covered, what tier it is on, what your copay or coinsurance will be, and whether prior authorization is required. Write down the answers and the date you called.
You can also check your plan's formulary online. Log into your plan's website, search for "levorphanol," and look at the coverage information. If the website is unclear or you cannot find the drug listed, call the plan. It is better to spend five minutes on the phone before your doctor writes the prescription than to discover at the pharmacy that the drug is not covered or costs far more than you expected.
What to do if your plan does not cover levorphanol or the cost is too high
If your plan does not cover levorphanol or places it on a tier where your copay is very high, you have several options. First, ask your doctor whether a generic opioid like morphine, hydromorphone, or codeine might work for your pain and costs less on your plan. Many people find these medications effective, and they are usually cheaper.
Second, check whether the manufacturer of levorphanol offers a patient information program. Some pharmaceutical companies provide free or low-cost medication to people who cannot afford it. Your doctor's office or pharmacist can help you look into this. Third, if you believe levorphanol is medically necessary and your plan's coverage is unreasonable, you can request a coverage information or appeal. Your plan must respond within a set timeframe, and you have the right to ask for an independent review if you disagree with the plan's decision.
Frequently Asked Questions
Does Medicare cover levorphanol if I have a Medicare Advantage plan?
Most Medicare Advantage plans include prescription drug coverage, so levorphanol would be covered if it is on your plan's formulary. However, coverage details vary by plan. Call your plan's customer service or check your formulary online to confirm that levorphanol is covered and what your copay will be.
Will I have to pay the full cost of levorphanol upfront and then get reimbursed?
No. When you fill a prescription at a pharmacy in your plan's network, you pay only your copay or coinsurance at the time of purchase. The pharmacy bills Medicare directly for the rest. You do not pay the full cost and wait for reimbursement.
Can my doctor prescribe levorphanol if my plan says it is not covered?
Yes, your doctor can prescribe it regardless of what your plan covers. However, you would pay the full pharmacy price out of pocket unless you request a coverage exception from your plan or find another way to pay, such as a patient information program.
What is the difference between a copay and coinsurance for levorphanol?
A copay is a fixed dollar amount you pay each time you fill the prescription — for example, $15 or $50. Coinsurance is a percentage of the drug's cost — for example, 25 percent. Your plan documents will tell you which one applies to levorphanol and at what amount.
If levorphanol is too expensive, can I ask my doctor for a different pain medication?
Yes. Talk to your doctor about the cost and ask whether another opioid or non-opioid pain medication might work for you and cost less on your plan. Your doctor can check your formulary with you or call your plan to find out which pain medications are covered at the lowest cost tier.