Does Medicare Cover Gabapentin? 

The nervous system is an incredible feat of engineering as the average human body contains around 37 miles of nerves. Virtually every part of your body is connected through your nervous system. All of the nerves in your body connect with your brain through your spinal cord, and it’s this pathway that controls everything from sensation to muscle movement.

Nerve conditions can affect anyone, but seniors often find themselves suffering from nerve problems more frequently compared to younger individuals. With time, various health conditions like diabetes, shingles and seizure disorders can be caused or exacerbated by nerve problems. When nerve conductivity is adversely affected by a health condition, medications like Gabapentin may be prescribed.

What is Gabapentin?

Gabapentin is a prescription drug most often prescribed to treat seizure disorders and nerve pain. This medication affects gamma-aminobutyric acid (GABA) which is a neurotransmitter in the brain. By attenuating GABA, Gabapentin has the effect of reducing electrical activity in the nervous system.

This makes Gabapentin a potential solution for overactive nerve conductivity that leads to loss of control of muscle function, seizures and nerve pain. Gabapentin is a generic medication, and it has also been shown to lower anxiety and blood pressure.

Does Medicare cover Gabapentin?

Since seniors often face problems with the nervous system with age, Medicare covers Gabapentin in several different ways. Gabapentin is covered by Medicare benefits under Part D, the prescription drug benefit, when the medication is prescribed by a Medicare-participating physician and is purchased from a local pharmacy. Medicare recipients may have a copay at the time of purchase, but this will depend on the details of each Part D plan. You can check your plan’s formulary for more information about Gabapentin coverage.

The cost of Medicare Part D depends on your plan and income. Some Medicare recipients simply pay their plan premiums, but others may face an additional premium. This is known as an income-related monthly adjusted amount (IRMAA) that is added to the plan premium. If you have to pay this additional premium, the amount depends on your level of income as reported on your tax return.

Medicare coverage for clinical Gabapentin administration

Gabapentin administered in a clinical setting will usually be covered by Medicare Part B, the outpatient benefit. Since Gabapentin is available as a pill that is taken orally at home, it isn’t likely to be administered in this setting, but if it is, Medicare recipients will pay 20% of the cost of the medication while Medicare coverage pays the remaining 80%.

Medicare Part B comes with a monthly premium requirement, and this cost is on a sliding scale similar to the IRMAA with Part D. This means that the cost of Medicare Part B goes up with your income. In 2023, the highest Medicare Part B premium is $560.60 per month, but in 2023, most Medicare recipients only pay $164.90 per month. 

Medicare Part B also provides coverage for medical services related to nerve pain, including medically necessary nerve testing and visits with specialists. If clinical nerve therapies are ordered by your physician or specialist, Medicare may cover durable medical equipment (DME) under Medicare Part B as well.

Medicare coverage for inpatient Gabapentin administration

Medicare recipients are provided up to 60 days of full inpatient coverage each benefit period. This coverage is available to pay for admittance to a Medicare-participating hospital, but only 20 days of full inpatient coverage are available for admittance to a skilled nursing facility.

If Gabapentin is given during a stay in an inpatient facility, Medicare Part A supplies coverage. Medicare benefits under Part A typically don’t require a monthly premium to keep current, but a deductible still applies to Part A coverage.