Does New Jersey Medicaid cover Suboxone®?

According to the Kaiser Family Foundation (KFF), approximately 3.3% of Medicaid enrollees have an opioid use disorder (OUD)¹. That comes out to roughly 2,900,000 people across the United States².

Individual states are taking this crisis seriously and providing Medicaid coverage for medications for addiction treatment (MAT). Medicaid increases access to care, so many people wonder what’s actually included in that coverage. If you have questions about Medicaid and OUD treatment in New Jersey, we’re here to help.

Does New Jersey Medicaid cover MAT?

Given the ongoing New Jersey opioid epidemic, the state has committed to helping people access the care they need. New Jersey FamilyCare, the state’s publicly funded insurance program, includes MAT coverage from several providers³:

• Aetna Better Health of New Jersey
• Fidelis Care
• Horizon
• UnitedHealthcare Community Plan
• Wellpoint

Each carrier has its own formulary, or list of covered medications; these lists sometimes differ in their coverage of brand-name Suboxone® and generic buprenorphine medications (important safety information).

What’s the difference between Suboxone + a generic?

Prescription likelihood

Insurance companies prefer generic medications as they’re usually 80% to 85% less expensive than the name brand⁴. Even if Suboxone and the generic equivalents are both covered, the generic versions of buprenorphine-naloxone are likely to be priced more favorably.

Chemistry

Generic buprenorphine-naloxone is just as safe as brand-name Suboxone because they’re made with the same active ingredients. Buprenorphine reduces withdrawal symptoms, and naloxone prevents misuse. The generic buprenorphine/naloxone was approved by the Food and Drug Administration (FDA) in 2018⁵ and has been consistently used in various MAT programs.  

Moreover, buprenorphine-naloxone is bioequivalent to Suboxone, meaning it has the same effect on the body. The differences are usually in the inactive ingredients, like binding agents and fillers. The medications may also differ in delivery method and color, but these differences wouldn’t impact how they work. 

Does New Jersey Medicaid cover Suboxone?

Brand-name Suboxone is still covered and can be prescribed for MAT as long as the prescribing clinician demonstrates medical necessity to the insurer. Medical necessity typically means a patient can’t tolerate generic alternatives or there are specific contraindications. 

In the case of generic buprenorphine-naloxone, some patients may experience allergic reactions to the binding agents or fillers. Such allergies are relatively uncommon, but they’re still possible, which is why New Jersey Medicaid covers brand-name Suboxone.

The state’s prior authorization process requires prescribers to submit detailed documentation to justify the use of the brand-name medication, which means clinicians can make a clear case for their recommendation before a claim is rejected.

Does New Jersey Medicaid cover telehealth for addiction treatment?

New Jersey has been expanding its telehealth coverage since the COVID-19 pandemic—and these changes have influenced the way the state is handling its opioid epidemic. Medicaid-covered telehealth options have proven to be particularly beneficial for MAT treatment, offering better access to critical healthcare services. Providers can conduct initial evaluations and offer ongoing medication management, while patients can receive treatment in the privacy of home without disrupting family and work obligations.

New Jersey law states that Medicaid and NJ FamilyCare programs will provide coverage and payment for Medicaid recipients seeking services through telehealth⁶ the same way they would handle in-person appointments. 

How can New Jersey residents receive OUD treatment through Ophelia? 

The first step is to talk with our enrollment team about your treatment needs and your insurance coverage. This call takes place over the phone.

After that, you’ll have a telehealth meeting with one of Ophelia’s clinicians to share your substance use history. It’s also important to establish your general medical history that helps our clinicians develop a customized care plan.

Ophelia’s clinicians will prescribe Suboxone or the generic buprenorphine-naloxone if medication-based treatment is right for you. The prescription will be sent to your preferred pharmacy. If there are any issues, our coordination team is available to help by phone, email, or even text. 

If you’ve never sought treatment before, don’t worry. Your prescription will have instructions for at-home induction to help you take the medication correctly. Once you’ve started taking buprenorphine, you’ll be asked to do an at-home urine drug screening. This test establishes a baseline for your treatment, and we don’t punish people or kick them off their medications if substances other than buprenorphine are detected.

We schedule weekly check-ins to ensure you’re doing well and adjust your treatment plan as needed. 

We also make additional support available to you at no extra cost. This can include addiction-related medical care, and treatment for associated psychological, psychosocial, or behavioral, psychological, and psychosocial conditions.

As you acclimate to treatment, your clinician may recommend a new pace for your virtual meetings. For example, you may be able to meet every other week and then step down to once a month depending on your progress. But we also have a triage team available 7 days a week to provide support for urgent matters.

If you need help for OUD in New Jersey, Ophelia is with you every step of the way.