Learn how buprenorphine and other medications used in medication-assisted treatment (MAT) are covered under Medicare, Medicaid, and other forms of health insurance.
The cost of different medications used in medication-assisted treatment (MAT) varies, and this may need to be taken into account when considering treatment options. The Affordable Care Act now requires most insurers to cover addiction treatment benefits. In addition, The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 requires health insurers and group health plans to provide the same level of benefits for behavioral health services that they do for primary care. However, not all insurance plans cover every available addiction treatment medication. And some plans cap the number of dosages and prescription refills a MAT patient receives. These limitations also factor into how people pay for MAT.
Learn more about health financing and how SAMHSA helps MAT professionals adapt to the new health care environment.
MAT Medications and Medicaid Coverage
A review of Medicaid policies in 2013 revealed that all 51 Medicaid programs include disulfiram and oral naltrexone and 31 programs include methadone on their Preferred Drug Lists (PDLs). If a medication is not included on the PDL, the prescriber must obtain permission from the member’s pharmacy benefit plan before the product can be prescribed, or the medication will not be covered. In 2013, only 13 state Medicaid programs included all available medications for treating alcohol and opioid use disorders in their Medicaid PDLs.
The SAMHSA publication Medicaid Coverage and Financing of Medications to Treat Alcohol and Opioid Use Disorders – 2014 explains Medicaid coverage of medications for substance use disorders.
Paying for Buprenorphine
Several factors determine how much a prescribed medication such as buprenorphine will cost patients. These include the pharmaceutical manufacturer, the insurer, the health plan (if any) or prescribing clinic, and the retail pharmacies that typically dispense the medication.
It is important to understand that the cost of the buprenorphine medication is only one part of the cost of outpatient opioid treatment. Other costs are incurred through physician visits and counseling services. These can include charges for laboratory analyses or emergency detoxification or stabilization, and any necessary ongoing service referrals and visits determined by the prescribing physician.
Medicare and Medicaid Coverage
Substance use treatment may be covered under Medicare (1) if it is medically necessary; and (2) if it is provided in an inpatient or outpatient treatment center that is Medicare-certified as determined by the Department of Health and Human Services (HHS).
Medicare does not generally cover prescription medications that are prescribed or dispensed to patients on an outpatient basis. However, if buprenorphine is administered by a Medicare-certified program or facility as a component of inpatient or emergency treatment such as detoxification or early stabilization treatment, the cost could be covered, as with any other medication used in the treatment process. The reimbursement would only occur if the Medicare-certified facility had buprenorphine on its list of eligible medications and if the patient received the treatment at the facility.
Medicaid coverage of substance use treatment and medications such as buprenorphine varies considerably by state and whether or not a state’s Medicaid plan is offered under managed care or HMO arrangements. Coverage in many states is also subject to rules about prior authorization and medical necessity. For buprenorphine-naloxone, a review of Medicaid policies in 2013 revealed that 50 Medicaid programs include the treatment medication on their PDLs.
Commercial Health Care Coverage
Health insurance through a commercial insurance plan may or may not cover all parts of buprenorphine medication. Several factors determine coverage, including:
- Medical necessity
- Whether medications are covered
- If there is a required co-payment
- If buprenorphine is on the plan’s approved medication list
Free Health Coverage at Community Health Centers, Clinics, and Hospitals
Free care for low-income patients offered at community health centers, clinics, and hospitals may or may not have buprenorphine available. The availability of the medication in these facilities depends on:
- Whether they offer substance use treatment or emergency care of chemical dependency
- If buprenorphine is on the list of eligible medications
- If a qualified staff or an attending physician associated with the hospital is available to administer the medication
- If the medication is medically necessary
People Who Are Uninsured
People without insurance coverage who are neither eligible for Medicare or Medicaid nor impoverished must pay for buprenorphine and any associated treatment themselves.