The world of insurance is complicated enough as it is, but when you add medication-assisted treatment (MAT) with Suboxone (buprenorphine/naloxone), things get even more confusing. And suffice it to say that there’s still a lot (read: a LOT) of work that needs to be done to cut through the frustrating bureaucracy and inertia of the insurance industry.
We won’t bore you with all the insurance specifics that we nerd out over day in and day out, because we know that what you’re most interested in knowing is whether insurance covers MAT.
So here’s the thing: there’s actually two components to MAT that insurance may or may not cover:
- Ophelia’s services (prescriptions, appointments, drug testing, behavioral health treatment, etc, etc).
- Medication (that you pick up from your local pharmacy)
If you have insurance, great! We accept a growing number of plans that may cover both or one of these components.
No insurance or aren’t in-network? No problem. We have a transparent, out-of-pocket pricing of $195/month for Ophelia’s services. No hidden fees, ever.
Below, we’re outlining everything you need to know about coverage (of both medication and Ophelia’s services), the cost of Suboxone, and more.
How much will I pay for Suboxone if I have insurance?
This is understandably the most frequently asked question we get. Unfortunately, there’s not a one-size-fits-all answer since the amount owed will vary based on your individual insurance plan and coverage. The two primary considerations are whether you have a copay or coinsurance/deductible.
- Copay: set dollar amount, typically less than $50
- Coinsurance/deductible: usually for a limited time throughout the benefit period until a total dollar amount is met, at which time you will hit the “cap” (out-of-pocket maximum) and pay nothing for the remainder of your coverage
How do I know if I’ll have a copay?
If applicable, the amount of your copay would be listed on your insurance card under: “Specialist/Specialty Care Copay.” Ophelia can help identify this for you.
Do I need a referral from my primary care provider in order to get insurance coverage?
It varies. Depending on your insurance, a referral may be required. In some cases, services may also require prior authorization from your health plan. Ophelia can assist with both of these if required.
If my insurance covers MAT, are ALL of Ophelia’s services covered (FDA-approved medications, behavioral health treatment, appointments, lab testing, etc) or are certain services billed separately?
Coverage for your brand name prescription medications may be separate from coverage for the appointments with your Ophelia provider – again, it depends on your specific plan. Medications are typically covered through your “Prescription Drug Benefit” while appointments would be covered through your “Medical Benefit Policy.”
Currently, for Ophelia services that are not related to the cost of your medication, you would only be responsible for the amounts your insurance company indicates based on your benefit policy (copay, coinsurance, or deductible).
If I have insurance that covers MAT, do I still need to pay upfront and then get reimbursed?
Nope. If you provide Ophelia with all of the required information needed to bill your insurance and sign our Financial Agreement that allows us to bill your insurance on your behalf, then you will not need to pay anything upfront. After Ophelia bills your insurance, you will likely receive an “Explanation of Benefits'' indicating how much (if anything) you owe. Once your insurance processes the claim, Ophelia will invoice you accordingly.
Is it possible for my health insurance to cover Suboxone treatment but only for a certain amount of time? Or do most cover it as long as it’s considered medically necessary?
It is possible for your health insurance plan to only cover Ophelia services for a certain period of time. However, Ophelia will work with you and your insurance company to provide as much notice as possible if services will no longer be covered — in addition to assisting you with any next steps (hand-off to another healthcare provider covered by your insurance, converting to self-pay instead of insurance, or discharging from care in a safe, compliant manner).
Am I either ALL covered or not covered at all? Or can I be partially covered?
It is possible for a patient to have coverage for some services, but not all. It is also possible for a patient to have their medication covered by their “Prescription Drug Benefit,” but not Ophelia’s other services.
What will I pay if I do not have insurance or are out-of-network?
You will pay our current set rate of $195/month, which includes all services you may receive from Ophelia (excluding the cost of medication).
If I’m denied insurance coverage, exceed my coverage limits, or can’t pay my deductible, are there any resources I can turn to for support?
Depending on your circumstances and treatment plan, you may be eligible for Medical Assistance (Medicaid), community assistance, or other means of access to care. For assistance determining Medicaid eligibility, refer to healthcare.gov.
What’s the difference between PPO and HMO?
There are a few key differences between these two plans:
HMOs generally require members to obtain a referral from their primary care physician in order to see a specialist, while PPOs do not.
- Out-of-network coverage
PPOs will cover services delivered by non-network health insurance providers (although their members pay a greater share of costs than for network care). HMOs only cover services provided by in-network providers.
Wait, if the Affordable Care Act of 2010 requires all long-term insurance policies to cover medically-necessary care for pre-existing conditions (including substance use disorder), why do certain insurance policies still not cover MAT? Also, according to the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008, insurance companies must pay for addiction treatment programs as they would for any other medical treatment, right?
All of this is correct; however, it’s been very difficult for the government to monitor. That said, the awareness of MAT services within the health plan space has increased significantly in recent years — the problem is that there can be some delay in health plans working through their own logistics around how to contract and pay for these services (inpatient or outpatient treatment centers).
Why do you accept certain insurance policies/plans in some states and not others?
Ophelia is continually working to become in-network with as many insurance companies as possible in the states we operate in. However, the coverage isn’t the same in every state. Here’s why:
- The health plan has indicated that they do not wish to contract with Ophelia because they already have an adequate network of MAT providers.
- Ophelia has just recently begun providing substance abuse disorder services in a state, with contracts yet to be finalized.
- The health plan and Ophelia cannot agree on the key terms to finalize a contract.
If two people in the same state have the same insurance — say, Blue Cross Blue Shield — but different plans (PPO vs HMO), will their coverage be different?
Yes. Benefit policies are largely controlled by the type of plan, whether it be commercial, medicare, medicaid, or exchange/marketplace.
- Commercial/Private Insurance
This is the most diverse product and can vary significantly from one patient to another. It’s largely driven by the patient’s employer and the type of policy that that employer has chosen to purchase from the insurance company.
- Medicare Advantage/Managed Medicare
If you are 65 years of age or older, you’re eligible for federal Medicare — either Original Medicare (also known as Medicare Fee-For-Service, or FFS) or Medicare Advantage (offers lower costs to the patient and more benefits such as dental or vision). For more information, refer to this official Medicare handbook.
As a state-funded program, Medicaid is typically the most straightforward plan/product since, within a single state, the benefits for Ophelia services will likely be identical. However, you cannot use your Medicaid coverage benefits from one state in another state. Also, the benefits and rates of payment vary significantly state-by-state.
Also known as Obamacare or the Affordable Care Act (ACA), Exchange/Marketplace are individual policies that you can purchase and, depending on your circumstances, have some of the monthly premium subsidized by the government. Most exchange plans follow the “metallic” structure (Bronze, Silver, Gold, Platinum), with benefits ranging from the very basic (Bronze) to the more comprehensive (Platinum), with costs increasing accordingly. Because these policies are purchased on an individual basis, they can vary significantly from one person to another. For example, two people who both have an Exchange product through Aetna may have two entirely different benefit designs based on whether they purchased Bronze or Gold. More information can be found here.
Want to know if your insurance plan covers substance abuse treatment options in your state? Text us at (215) 585-2144.
Interested in learning more?
Refer to the Substance Abuse and Mental Health Services Administration (SAMHSA) site for information on mental illness and/or substance use disorders (both opioid use disorder and alcohol addiction interventions).