Understanding insurance coverage for Suboxone and MAT: A guide for Keystone First members in Pennsylvania

Access to medications for addiction treatment (MAT) and Suboxone® medication is crucial for individuals seeking treatment for opioid use disorder (OUD). As a Keystone First member in Pennsylvania, understanding your insurance coverage for these treatments is essential. In this article, we will delve into the insurance coverage provided by Keystone First, including their partnership with Ophelia to expand access to Suboxone (important safety information) and MAT. By gaining insights into your coverage, you can confidently pursue your journey toward a healthier life.

Does Keystone First cover MAT?

MAT—which combines medications for addiction treatment, such as Suboxone, with counseling and behavioral therapies—is widely recognized as the most effective treatment approach for OUD. Individuals with Keystone First are eligible for coverage for MAT services.

Does Keystone First cover Suboxone for OUD?

Individuals with Keystone First insurance are eligible for the coverage of evidence-based opioid addiction treatment programs and medications used in MAT, including Suboxone. Keystone First is a Medicaid managed care health plan, and in Pennsylvania, Medicaid covers Suboxone. Both Suboxone and generic versions are covered by Medicaid in PA under a fee-for-service (FFS) model¹. 

As a Keystone First member, you have access to Suboxone through participating providers, including the option to utilize Ophelia’s opioid addiction treatment services. However, it's important to note that coverage for specific medications can vary depending on your insurance plan's formulary. Please consult your plan documents or contact Keystone First directly to confirm the inclusion of Suboxone or another brand-name or generic buprenorphine medication in your plan's formulary. You can also use Keystone First’s searchable drug formulary to find more information. 

Keystone First telehealth coverage

In recent years, telehealth appointments have become much more popular. Millions of Americans now use telehealth to access critical health services, including OUD treatment. Individuals covered by Medicaid and Medicare are some of the most likely to use telehealth services, yet many still wonder whether their insurance plans will cover telehealth care².

Keystone First does cover some telehealth services, which is good news for Keystone First members interested in telehealth OUD care³. Patients may prefer to access services like OUD treatment via telehealth for a variety of reasons, including provider access and greater privacy and flexibility. 

Telemedicine has transformed opioid addiction treatment by helping remove location barriers to care, making it more accessible to those who don’t have OUD care providers nearby.

Telehealth also makes short- and long-term addiction treatment programs accessible from the comfort of home, which makes Ophelia a valuable option for people who would otherwise have to travel long distances or disrupt their family routines for in-person care. Ophelia even recently became the first and only telehealth provider to be named a Center of Excellence (COE) in Pennsylvania, highlighting our dedication to improving patient outcomes by providing high-quality virtual OUD care. 

Understanding your Keystone First insurance coverage for Suboxone and MAT

Use the following steps to navigate your insurance coverage effectively:

• Review insurance policy and formulary: Take the time to review your Keystone First insurance policy documents and formulary. Look for sections that outline coverage for addiction treatment, prescription medications, and the specific medications used in MAT, such as Suboxone.
• Consult with Ophelia: We can provide additional guidance and support in understanding your insurance coverage with Keystone First. Our care coordinators can help you navigate the insurance process, answer questions specific to your treatment plan, and assist with any financial concerns. Text us today at (215) 585 2144.
• Contact Keystone First: Reach out to Keystone First directly to inquire about your coverage for Suboxone and medications for addiction treatment (MAT).

Using Keystone First insurance with Ophelia for effective treatment

Accessing telehealth OUD treatment through Ophelia is a straightforward process designed to fit your needs and schedule. You start with a quick virtual welcome call to discuss your eligibility and address any questions you have about treatment or your Keystone First coverage for Ophelia’s services.

Next, you’ll have your first visit with your clinician to design your personalized addiction treatment program, including a Suboxone prescription if eligible—all virtually. The members of your care team will provide ongoing support and be there when you need them throughout the treatment process. Start your journey to recovery today and experience the benefits of online MAT.