Medicare plans can have different formularies, but most should cover a generic version of Suboxone without major issues as well as other kinds of addiction treatment. The most relevant section of a Medicare plan for drug coverage is Part D.
Does Medicare Cover Suboxone Treatment for OUD?
There is no singular “Medicare” plan, as there are several plans available. For drug cost coverage, Medicare Part D specifically is generally going to be most relevant to your plan.
Every plan has an associated formulary, which lists the drugs covered by your plan and at what tier. The higher the tier number of the drug, the more expensive it tends to be.
Typically, a plan is more likely to cover the generic version of Suboxone (buprenorphine-naloxone sublingual film) than the brand-name medication. If it covers both, the generic version will still be in a better tier and thus cheaper.
Fortunately, generic drugs are monitored by the FDA and can only have that label if they copy the associated brand-name medication in more or less all areas that matter for the purpose of medical care, including in terms of safety, strength, quality, and performance.
What Affects Coverage for Suboxone or MAT?
The specifics of your Medicare coverage will depend on your plan. The government website Medicare.gov can help you explore your options. If you don’t know where to begin, this tool can help you find plans relevant to you.
Pay attention to how drug costs are covered by a given plan. If possible, look through the plan’s formulary to make sure the medications you need are covered. A generic version of Suboxone is usually present on most formularies, but it is important to check.
MAT Coverage Under Medicare
Most of what has already been discussed also applies to other forms of Medication for Addiction Treatment (MAT). If a medication is on a formulary, it will be covered based on the tier assigned to it and how your plan handles medications of that tier.
One exception is methadone because this drug has to be administered at specialized sites rather than given directly to a patient at a pharmacy for use later.
Does Medicare Cover Addiction Treatment Covered Beyond MAT?
Medicare plans usually cover addiction treatment services, including these:
- Early screening
- Patient education
- Post-hospitalization follow-up care
- Psychiatric hospital stays
- Therapy or counseling
There are notable and controversial caveats to this coverage. For example, there is a 190-day total lifetime limit on specialized psychiatric hospital stay coverage. While this is a fairly high limit for most people’s needs, those who struggle with severe addiction and have relapsed several times, or who have dealt with other serious mental health issues in the past, may eventually hit this limit.
Checking Your Medicare Coverage for MAT
The U.S. Centers for Medicare and Medicaid Services has designed a free search tool to help people check what their Medicare plans cover. It has some links you can follow if the tool doesn’t get you the exact information you’re looking for.
It also helps to thoroughly read through your Medicare plan’s different sections, so you can fully understand what is and isn’t covered and how much you may still need to pay even on partially covered costs. This ensures you will know exactly what you can expect to pay out of pocket instead of being surprised when the bills come later.
Talk to your treatment provider as well as Medicare to get a clear idea of exactly what will be covered.