Opioid use disorder (OUD) impacts millions of Americans from all walks of life, regardless of their age, profession, income, or ethnicity. However, certain factors have been identified as putting individuals at higher risk of OUD's debilitating effects, from geographic location to socioeconomics. People in programs like Medicaid—a government program to cover medical costs for low-income individuals—may be particularly susceptible.
The good news is that Medicaid does cover medications for addiction treatment (MAT) for those living with OUD. That said, there are eligibility requirements as well as distinctions in what type of MAT is covered. Additionally, Medicaid coverage varies between states.
Suboxone® (important safety information) is one medication commonly used to help manage OUD. But does Medicaid cover it? Here’s what you need to know before starting treatment.
Prevalence of OUD in Americans enrolled in Medicaid
A substance use disorder (SUD) is a mental disorder characterized by a person's inability to control their use of alcohol, drugs, or medications. In the case of OUD, opioids are the substance in question. These could be legal drugs—like oxycodone (OxyContin®) and hydrocodone (Vicodin®)—or illegal drugs, like heroin.
It's estimated that 12% of Medicaid beneficiaries over 18 live with an SUD. Some of those may be grappling with OUD specifically. In particular, individuals with dual eligibility for Medicare and Medicaid—the federal health insurance program for those 65 and older—show a higher burden of OUD than those who are only enrolled in Medicaid.
Types of MAT covered by Medicaid
MAT is considered the gold standard of OUD treatment. This approach to treating OUD takes a whole-person approach, addressing the various aspects of addiction—physical, mental, and social. It's rooted in the use of medications to control withdrawal symptoms and cravings, usually coupled with therapy or counseling.
Suboxone has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of OUD since 2002. Does Medicaid cover Suboxone? The answer isn’t straightforward.
In general, Medicaid coverage varies between states. Brand-name medications, like Suboxone, are often only covered by Medicaid if there is no generic alternative. The first generic versions of Suboxone sublingual film were approved by the FDA in 2018.
Generic medicines may have a different name and look from the brand-name originals, but they still contain the same active ingredients and have the same effect. Generic equivalents of Suboxone contain buprenorphine and naloxone, the active ingredients of Suboxone. A generic isn't "worse" than the brand name and there should not be cause for concern if you are prescribed a generic instead of a brand name.
The good news is that medications for addiction treatment are covered in all of Ophelia’s operating states, meaning patients have access to brand-name and generic options.
Eligibility for MAT through Medicaid
You have to be eligible for Medicaid in the first place to use the benefits for OUD treatment. Medicaid eligibility depends on your income and family size, and precise qualification rules differ between states. If you are not yet enrolled in the program, you can apply for Medicaid directly with your state or over the Health Insurance Marketplace®. Eligibility requirements vary between states. These variations can include copayments on medications, prior authorizations from healthcare providers, and quantity limits.
Ophelia patients in New York, New Jersey, and Pennsylvania are able to have their treatment covered by Medicaid. In New York and New Jersey, there is no copayment for service, though New York does have a cost-sharing program for prescription drugs based on the enrollee’s income relative to the federal poverty level. Meanwhile, Pennsylvania’s copays are $1 for generic medications and $3 for brand names. Pennsylvania also requires prior authorization for prescriptions in limited situations.
Medicaid coverage of telehealth treatment
In general, Medicaid covers SUD treatment. However, there are limits on the extent of SUD treatment services a person can use in a year. And there are other limits. For example, although Medicaid may cover inpatient treatment programs, it may not cover related expenses like room and board. These added costs can make inpatient care cost prohibitive.
The good news? Telehealth programs can offer a cost-efficient alternative. Ophelia's telehealth OUD program accepts Medicaid in a number of states. With Ophelia, eligible patients can get the care they need from the comfort of their own homes.
How does it work? A Suboxone prescription is sent to your local pharmacy, and you have access to a dedicated care time through regular online visits. Your clinical team will include clinicians, nurses, and care coordinators, as well as peers who have either been in your position or are close to someone who has been there.
This online approach can help improve access to care, such as in rural communities where geographic barriers make access to MAT especially tricky. And the great news: Research suggests that retention in such telehealth services is high.
If you believe you could benefit from MAT through Ophelia, sign up for a free 15-minute welcome call. You will have to answer a few questions, and we will help you figure out your coverage options while we're at it.
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