Like most of the United States, Pennsylvania is struggling with an opioid use disorder (OUD) epidemic. The state's attorney general has even named the issue as Pennsylvania's number one public health and safety crisis with an average of 14 Pennsylvania residents dying from overdose every day.
While OUD can impact anyone, certain groups are recognized as being at higher risk, with socioeconomics identified as a significant factor. Recipients of Medicaid—a government program that covers medical costs for low-income persons—may be especially susceptible. An estimated 12% of Medicaid beneficiaries over 18 live with a substance use disorder (SUD).
To address its OUD crisis, Pennsylvania covers various medications for addiction treatment (MAT) through its Medicaid program. MAT is considered the gold standard of care for OUD and involves prescribing medications to help manage cravings and withdrawal symptoms.
Suboxone® (important safety information) is one medication commonly used in OUD treatment. However, it's not covered by Medicaid in all cases. Some states may include Suboxone only if there is no generic alternative, for instance. Learn more about the ins and outs of Medicaid Suboxone coverage in Pennsylvania below.
Does Medicaid cover Suboxone in PA?
Suboxone is often prescribed as part of MAT programs to address the physical components of addiction. It's made up of two substances, buprenorphine and naloxone, and can be administered as a film or tablet.
Unfortunately, accessing Suboxone through Medicaid is not always easy. Many state Medicaid programs require patients to get prior authorization for MAT before covering it. Prior authorization can be a burdensome process. For example, some states require patients to participate in counseling or group therapy as a precondition for receiving buprenorphine.
Prior authorization requirements may go hand in hand with other restrictive elements that make MAT harder to access and implement. States may have complicated surveillance initiatives, for instance, that require recipients to participate in random screenings or pill counts.
For Pennsylvania residents, there's good news: The state has made a concerted effort to remove such barriers. Medicaid covers Suboxone, as well as generic versions, in PA under a fee-for-service (FFS) model. Furthermore, the state has taken steps to remove barriers to access, not only for Medicaid recipients, but also for all insured Pennsylvanians.
In 2018, the state reached an agreement with seven major insurers to improve MAT coverage by offering a broader range of medications, including buprenorphine and naloxone. The agreement also made MAT more affordable, making it accessible at the lowest cost-sharing tier. Finally, the move eliminated prior authorization requirements.
Pennsylvania Medicaid guidelines for covering telehealth treatment
Cost is just one factor that can stand in the way of people accessing MAT. Location can be another barrier.
Case in point: OUD has proved particularly challenging in rural communities. There are various reasons for this, from limited resources and personnel in rural areas to geographic barriers to points of care. Stigma can also be an issue in small communities where people are more intimately acquainted.
Telehealth treatment offers a solution. With telehealth MAT programs, like Ophelia's, individuals can get the care they need from the comfort and privacy of their own home. A Suboxone prescription is called into the patient's local pharmacy, while mental health services are provided via online video appointments.
Telehealth services for buprenorphine show high retention rates, regardless of geography, suggesting this is an effective way to help rural communities struggling with OUD. In Pennsylvania, where about 26% of the state's 13 million residents live in rural counties, many people can benefit from telemedicine.
Recognizing the value of telehealth treatments, Pennsylvania is also taking steps to expand Medicaid coverage in this area. The state's Medicaid program reimburses live video telehealth, along with remote patient monitoring, benefits that apply directly to Ophelia’s services.
Additionally, in July 2024, Pennsylvania's governor signed the Pennsylvania Telemedicine Bill into law, further expanding coverage for all insured persons in the state, including Medicaid recipients. The initiative was taken with rural communities in mind.
Law SB739 requires health insurance and managed care plans to pay for covered health services provided through telemedicine. Commercial health insurers that provide coverage for a service performed in person must provide the same level of coverage for telemedicine, provided the same standard of care is met.
Start your MAT journey with Ophelia
Ophelia is committed to making MAT more readily accessible through dedicated telehealth services and 100% Medicaid coverage in Pennsylvania. How does it work?
The first step is a 15-minute welcome call during which our onboarding team will help to determine your eligibility and coverage. Completing a quick survey before the call will streamline the process, and it takes less than five minutes.
You'll then be connected with a virtual clinical care team over a video appointment. Assuming you are eligible, a Suboxone prescription will be called into your local pharmacy. You will be given a customized treatment plan and receive ongoing medical support, available seven days a week, online.
Ophelia even makes it possible to do at-home drug testing. The testing kit is delivered to your door in a discrete, unmarked package. You wait to open the kit until you have a video call with your clinician. After opening the kit on camera, you take it to the bathroom to pee in the cup in privacy, before returning to the video call to show your clinician the results.
With initiatives like these, Ophelia makes getting help for OUD easier and less stressful, causing minimal disruption to everyday life. Get the gold standard of treatment at home, in a way that works for you.
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