What to Know About Medicare and Lyrica Coverage

• Lyrica (pregabalin) is a medication most commonly prescribed to treat pain due to fibromyalgia and nerve pain associated with other health conditions. 

• While Original Medicare does not include prescription drug coverage, beneficiaries can enroll in a separate drug plan known as Medicare Part D. Medicare Advantage plans may also include prescription drug coverage.

• Costs for Lyrica will vary widely, and some Medicare plans may only cover the generic version, pregabalin. 

• There are ways to help with prescription drug costs, including GoodRx, Medicaid, Extra Help program, etc.

Lyrica (pregabalin) is a prescription medication used to treat pain associated with fibromyalgia and nerve pain with other health conditions such as diabetes. It is available in both brand and generic versions.

Read on below to learn more about how coverage for Lyrica works with Medicare, including how Medicare drug coverage works in general.

Lyrica is the brand-name version of pregabalin. Health care providers often prescribe Lyrica for those who need to manage pain associated with nerve malfunction such as fibromyalgia, spinal cord injury, neuropathy, or Shingles.

Warnings and Side Effects

According to the Federal Drug Administration (FDA), common side effects include: 

• Dizziness

• Drowsiness

• Swelling of hands and feet

• Weakness

• Dry mouth

• Constipation

• Blurry vision

• Accidental Injury

• Weight gain

Lyrica can also cause a severe allergic reaction. Signs of this include:

• Hives or blisters

• Trouble breathing

• Facial, mouth, or throat swelling

Anyone who is experiencing the aforementioned signs of an allergic reaction should seek emergency medical attention immediately. 

How Expensive is Lyrica?

Lyrica can cost over $700 monthly without health insurance. Pregabalin can cost over $300 monthly without health insurance. 

The overall cost of Lyrica will vary based on the Medicare plan a beneficiary has enrolled in. As well, each individual health plan will have its own set of coverage rules. For example, some plans may have a limit on how much Lyrica a beneficiary is allowed to fill at one time. Medicare beneficiaries need to contact their insurance company to confirm coverage.

As well, even with a health plan, brand name Lyrica can be quite expensive. Unless there is a specific reason for taking the brand name version of Lyrica, the generic drug will always be a better value.

As a reminder, Original Medicare only consists of Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). These Medicare Parts do not include coverage for prescription drugs such as Lyrica. As such, those who only have an Original Medicare plan need to enroll in a Medicare drug plan, known as Medicare Part D, in order to receive coverage for prescription drugs.

Medicare Part D is Medicare’s prescription drug coverage. Most Medicare drug plans include a monthly premium, yearly deductible, and copayments or coinsurance. Medicare drug plans’ overall costs will vary. Factors that contribute to costs include:

• What prescriptions a beneficiary needs and whether they’re on the insurance plan’s list of covered prescription drugs, known as the plan’s formulary

• What tier the medication is in

• Which drug benefit phase the beneficiary is in (i.e. whether they’ve paid their deductible or if they’re in the catastrophic coverage phase) 

• What pharmacy is being used

• Whether a beneficiary is enrolled in the Medicare Extra Help program

Medicare enrollees are encouraged to compare Medicare prescription drug plans to find the best option for them.

Note: Learn more about Medicare Part D costs.

Does Medicare Part D Cover Lyrica? 

Some Medicare Part D plans may cover Lyrica, but it will depend on the specific plan chosen. In general, brand-name drugs are typically more expensive than generic drugs. That said, all Medicare Part D drug plans will cover pregabalin, the generic form of Lyrica.

Medicare Advantage plans, also known as Medicare Part C or MA plans, may include prescription drug benefits. MA plans are Medicare plans provided by private insurance companies that are Medicare-approved. Medicare Part C plans consist of the standard Medicare coverage (Medicare Part A and Medicare Part B), in addition to other healthcare benefits including vision, hearing, and prescription drugs. Exact benefits will vary per plan.

Note: Learn more about MAPD plans.

Do Medicare Advantage Plans Cover Lyrica?

Some Medicare Part C plans may cover prescription medications such as Lyrica. However, it will depend on the specific MA plan chosen since not all Medicare Advantage plans include coverage for prescription drugs. If an MA plan does include prescription drug coverage, beneficiaries can look at their plan’s formulary for a list of covered drugs to see if Lyrica is included.

Out of pocket costs for prescription medications can add up quickly, even with coverage. There are a number of programs that can help Medicare beneficiaries with these drug costs, however.

Extra Help Program

The Extra Help Program is a Medicare program to help beneficiaries with limited income or resources pay for a Medicare prescription drug plan. Some people automatically will qualify for Extra Help, such as those who qualify for the QMB program, SLMB, or QI program under Medicare Savings Programs.

Those who do not automatically qualify can apply here.

SHIP

The State Health Insurance Assistance Program (SHIP) is a national program that helps Medicare beneficiaries, caregivers, and family members make informed choices about their Medicare benefits and navigate all of their options.

Note: Learn more about SHIP.

GoodRx

GoodRx is both a website and mobile application that finds discount pricing for prescription medications. Visit its Lyrica page to learn more.

Medicaid (Dual Eligibles)

Beneficiaries eligible for the Medicaid ​“Dual Eligibles” program will be eligible to use the Medicaid Drug Rebate Program (MDRP). This program helps to offset the Federal and state costs for prescription drugs.

Note: Learn more about Medicaid Drug Rebate Program.

PACE

PACE stands for Program of All-Inclusive Care for the Elderly. It is a Medicare and Medicaid program that provides all the care and services covered by Medicare and Medicaid if authorized by someone’s health care team. This includes prescription drugs. Those in a PACE program do not need to enroll in a separate Medicare Part D drug plan.

Note: Learn more about PACE.

Medigap/​MedSupp

Medigap or MedSupp plans are supplemental Medicare plans that intend to ​“fill in the gaps” of Original Medicare. Medigap plans often help with deductible, copayment, and coinsurance payments. 

When it comes to prescription drugs, someone cannot be enrolled in both a Medicare prescription drug plan as well as a have a Medigap policy with drug coverage. Learn more about Medigap and Medicare drug coverage.

Is there a generic drug of Lyrica?

Yes, it is called pregabalin and is often less expensive than brand-name Lyrica.

Does Medicare cover Lyrica?

No, original Medicare plans do not include prescription drug coverage, meaning beneficiaries are not covered for Lyrica. However, if patients have a Medicare Advantage plan or standalone Part D plan, they may be eligible for coverage on prescription drugs like Lyrica.