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Does Medicare Cover Naltrexone

Does Medicare Cover Naltrexone?

There are a number of treatment options for those with an addiction to drugs or alcohol. Counseling and rehab facilities are a couple of common options.

There are also prescription medications that can help. One prescription med that’s used often is Naltrexone. This drug blocks the “high” sensation that drugs and alcohol give off. By doing so, it can help lower the dependence on addictive substances that people can feel.

If this is a treatment you are considering, you may have the question, “does Medicare cover Naltrexone?” In this article, we answer that question in clear, plain English. You will also find the average costs of Naltrexone for those who have to pay out of pocket for this drug.

Does Medicare Cover Naltrexone?

The short answer is no. In most cases, Medicare will not cover the cost of Naltrexone. That said, there may be some situations where you can get these costs covered. Below we’ll take a closer look at this to see when you might be able to get Medicare to pay for your Naltrexone. 

Original Medicare

Medicare Part A and Part B (Original Medicare) do not provide coverage for Naltrexone. Original Medicare mainly covers medically necessary services, equipment, and treatment rather than prescription drugs. Prescription drug coverage may be provided by either Medicare Advantage plans or Medicare Part D. 

There is also an injectable form of Naltrexone known as Vivitrol. Original Medicare provides coverage for your Vivitrol if it is considered medically necessary. Your healthcare provider must first order the treatment for Original Medicare to provide coverage.

Coverage for Vivitrol is provided by Medicare Part B. Medicare Part B includes coverage for Vivitrol if your healthcare provider administers it. 

Part C and Part D Coverage for Naltrexone

However, some Medicare Advantage plans (Medicare Part C) provide coverage for Naltrexone. Medicare Advantage plans must cover everything Original Medicare covers, as well as additional benefits not included in Original Medicare. However, what a Part C plan covers and how much the out-of-pocket costs are, vary for each plan.

Medicare Part C plans that include prescription drug plans will also provide coverage for medications that your healthcare provider will prescribe to you.

Medicare Part D plans also provide coverage for Naltrexone. Part D is a prescription drug plan, and just like Medicare Part C, Medicare Part D plans are provided by private insurance companies. One hundred percent of both Medicare Part C and Part D plans provide coverage for the medication Naltrexone. 

Naltrexone is listed as a Tier 2 drug in the Medicare drug formulary. Tier 2 medications are in the middle tier of drugs. Tier 2 medications are more expensive than Tier 1 but less expensive than Tier 3 and 4 drugs.

How Much Does Naltrexone Cost?

The average cost of 30 tablets of 50 mg of Naltrexone is right around $100. This cost may vary depending from pharmacy to pharmacy.

Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage. Always be sure to double-check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.

Additional Info on Medicare Coverage

This article is part of our series on “What does Medicare cover?”

Also, you can check out other articles in this series, including: Does Medicare cover Lidocaine Patches?

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Medicare Plan Tips Team

Annie Kaye is a writer and researcher who was thrown into the Medicare world while taking care of her ailing mother. Even with a degree in Library Science and a long history of fighting for what's right, she felt lost. She learned a lot about Medicare during that time and now writes to help others understand how the system works.