H.R. 1227: Alternatives to PAIN Act
Sponsor
Mariannette Miller-Meeks
Republican · IA-1
Bill Progress
Latest Action · Feb 12, 2025
Referred to Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned. for review
Medicare shouldn't make you try an opioid first
Why it matters
A Medicare patient can owe the full Part D deductible — roughly $615 in 2026, per CMS — before a non-opioid painkiller is even covered, plus prior-approval paperwork and plan rules that can require trying an opioid first. H.R. 1227 would wipe out the deductible for a narrow set of these drugs, move them to the cheapest copay tier, and bar prior authorization and opioid-first rules beginning in 2026.
H.R. 1227, the Alternatives to PAIN Act, changes how Medicare Part D treats certain non-opioid pain drugs. Starting with 2026 plan years, a qualifying drug would skip the Part D deductible entirely and sit on the plan's lowest cost-sharing tier — the cheapest copay rung instead of the specialty tier where new brand drugs often land.
It also strips out two common insurance gatekeepers. Plans could not require prior authorization for a qualifying drug, and they could not run step therapy that forces a patient to use an opioid before the non-opioid drug is covered. The same deductible and low-tier protections extend to people on Medicare's low-income subsidy.
The catch is the definition. A drug only qualifies if the FDA has approved it for postoperative or other acute pain, it does not act on the body's opioid receptors, no therapeutically equivalent product is already sold in the U.S., and a month's supply stays under Medicare's specialty-tier price ceiling. Together those tests point at a small set of newer brand-name drugs — the FDA approved the first non-opioid in this acute-pain class, suzetrigine (Journavx), in January 2025 — not the broad world of non-opioid pain care like generic ibuprofen.
Sponsors frame the bill as addiction prevention: if insurance rules make opioids the path of least resistance, patients may end up on them even when a non-opioid would do. The harder question for committees is cost — lowering cost-sharing and removing plan management tools for a class of higher-priced brand drugs could raise Medicare spending, and the bill carries no estimate.
H.R. 1227 Bill Summary
What H.R. 1227 actually does.
No deductible on qualifying non-opioid pain drugs
Starting with 2026 plan years, Part D plans could not apply the annual deductible before coverage begins for a qualifying non-opioid pain drug.
Cheapest copay tier, not the specialty tier
Plans would have to place qualifying drugs on their lowest cost-sharing tier, which generally means lower copays or coinsurance than the specialty tier.
Plans can't require an opioid first
Plans could not use step therapy to require a patient to try an opioid before covering a qualifying non-opioid pain drug.
No prior authorization
Plans could not require advance approval before covering a qualifying non-opioid pain drug.
Same protections for low-income enrollees
Medicare beneficiaries who receive the Part D low-income subsidy would get the same deductible and low-tier treatment for qualifying drugs.
A narrow definition of which drugs count
A drug qualifies only if it is FDA-approved for acute pain, does not act on opioid receptors, has no therapeutically equivalent product already marketed in the U.S., and stays under Medicare's specialty-tier monthly price ceiling.
Who benefits from H.R. 1227?
Medicare patients recovering from surgery or injury
Seniors prescribed a qualifying non-opioid drug after surgery or an acute injury would skip the Part D deductible — roughly $615 in 2026 per CMS — and pay at the plan's lowest copay tier.
Patients who want to avoid opioids
Anyone who would rather not start on an opioid, including people with a history of dependence, gets a path to a non-opioid option a plan can no longer gate behind an opioid trial.
Low-income Medicare beneficiaries
People on the Part D low-income subsidy (Extra Help) get the same no-deductible, lowest-tier treatment, limiting what they pay out of pocket for qualifying drugs.
Makers of qualifying non-opioid drugs
Manufacturers of drugs that meet the definition — a small group today — would see their products covered on favorable terms with prior authorization and step therapy off the table.
Who is affected by H.R. 1227?
Medicare Part D plans
Plans lose the deductible, tier placement, prior authorization, and opioid-first step therapy as tools for this class of drugs.
Pharmacy benefit managers
PBMs would have fewer levers to steer utilization or negotiate around these products.
The Medicare program and taxpayers
If more enrollees use higher-priced brand drugs at lower cost-sharing, Part D spending could rise; the bill includes no cost estimate.
Patients currently routed to an opioid first
Their treatment path could change, since a plan could no longer require an opioid trial before covering a qualifying non-opioid drug.
HR1227 Legislative Journey
House: Committee Action
Feb 12, 2025
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
About the Sponsor
Mariannette Miller-Meeks
Republican, Iowa's 1st congressional district · 5 years in Congress
Committees: Veterans' Affairs, Energy and Commerce
View full profile →
Cosponsors (80)
This bill has 80 cosponsors: 40 Democrats, 40 Republicans, reflecting bipartisan support. Cosponsors represent 32 states: Alabama, Arkansas, Arizona, and 29 more.
Nanette Barragán
Democrat · CA
Mike Kelly
Republican · PA
Jimmy Panetta
Democrat · CA
Carol Miller
Republican · WV
John Larson
Democrat · CT
Nicole Malliotakis
Republican · NY
Seth Moulton
Democrat · MA
Troy Balderson
Republican · OH
Michael Guest
Republican · MS
Yvette Clarke
Democrat · NY
Nikki Budzinski
Democrat · IL
Ted Lieu
Democrat · CA
Committee Sponsors
Ways and Means Committee
11 of 45 committee members cosponsored
Energy and Commerce Committee
16 of 54 committee members cosponsored
38 Republicans across these committees haven't cosponsored yet. Mobilize their constituents
H.R. 1227 Quick Facts
- Committee
- Ways and Means
- Chamber
- House
- Policy
- Health
- Introduced
- Feb 12, 2025
Referred to Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned. for review
Feb 12, 2025
Official Sources
Official bill text, cosponsors, actions, and status for the Alternatives to PAIN Act in the 119th Congress.
CMS overview of the Medicare Part D benefit that this bill amends, including formulary guidance and plan information.
FDA announcement of the first drug in the class this bill targets: a non-opioid for moderate to severe acute pain, approved January 2025.
The bill uses Orange Book therapeutic equivalence ratings to determine which drugs qualify; a drug with an equivalent already marketed does not qualify.
FDA draft guidance encouraging sponsors to develop non-opioid analgesics for acute pain, the same drug category this bill covers.
The bill extends its deductible and cost-sharing protections to low-income Medicare beneficiaries eligible for Extra Help.
Official CMS guidance for the 2026 Part D benefit structure, including the $615 deductible and $2,100 out-of-pocket cap that this bill interacts with.
The federal statute this bill directly amends to add a new paragraph (10) exempting qualifying non-opioid drugs from deductibles and placing them on the lowest tier.
Who is lobbying on H.R. 1227?
2 organizations lobbying on this bill
VERTEX PHARMACEUTICALS INCORPORATED | 4 |
VERTEX PHARMACEUTICALS INCORPORATED | 4 |
Showing 1-2 of 2 organizations
H.R. 1227 Common Questions
What does the Alternatives to PAIN Act (H.R. 1227) actually do?
It changes Medicare Part D so a narrow set of non-opioid pain drugs skip the deductible, sit on the cheapest copay tier, and can't be subject to prior authorization or a rule requiring you to try an opioid first. The changes start with 2026 plan years.
Would I still pay the Medicare deductible for these non-opioid pain drugs?
No. For a qualifying non-opioid pain drug, the Part D deductible would not apply — so you would not have to pay it down (roughly $615 in 2026, per CMS) before coverage kicks in.
Can my Medicare plan make me try an opioid before covering a non-opioid painkiller?
Not for a qualifying drug. The bill bars step therapy that requires an enrollee to use an opioid before the plan will cover a qualifying non-opioid pain drug.
Does H.R. 1227 ban prior authorization for these drugs?
Yes. For a qualifying non-opioid pain drug, a Part D or MA-PD plan could not require prior approval before the drug is dispensed.
Which drugs would actually qualify?
A drug qualifies only if the FDA approved it for postoperative or other acute pain, it doesn't act on opioid receptors, no therapeutically equivalent product is already sold in the U.S., and a month's supply stays under Medicare's specialty-tier price ceiling. The FDA approved the first such drug, suzetrigine (Journavx), in January 2025.
When would the changes take effect?
The deductible relief, lowest-tier placement, and the bans on prior authorization and opioid-first step therapy all apply to Medicare plan years beginning on or after January 1, 2026.
Does it help people who get Medicare's low-income subsidy (Extra Help)?
Yes. The no-deductible and lowest-tier protections for qualifying drugs also apply to low-income Part D beneficiaries who receive Extra Help.
Does this cover chronic pain or only acute pain after surgery?
Only acute pain. A drug qualifies only if it has an FDA-approved indication for postoperative pain or another form of acute pain, so chronic-pain drugs are not covered by these protections.
Based on H.R. 1227 bill text
H.R. 1227 Bill Text
“To amend title XVIII of the Social Security Act to ensure appropriate access to non-opioid pain management drugs under part D of the Medicare program.”
Source: U.S. Government Publishing Office
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