Does Insurance Cover Suboxone Treatment?
Reforms to health insurance, like the Affordable Care Act (ACA), mean that Suboxone and similar Medication-Assisted Treatments (MATs) are considered essential services, so health insurance must cover at least some of the cost. Medicaid also provides some coverage for MAT like Suboxone.
However, insurance billing complexities mean you may wait for days or weeks before receiving a prescription, which can make remaining in treatment tough. Some states are exploring ways to change this. Meanwhile, stay motivated with mutual support groups, your doctor’s support, and even a detox program.
What Is Suboxone?
Suboxone is the brand name for an important prescription drug used in Medication-Assisted Treatment (MAT). This is a combination of buprenorphine, a partial-opioid agonist, and naloxone, a drug that can temporarily stop an opioid overdose.
The combination, when taken as prescribed, releases buprenorphine into the system, allowing the person to function without cravings for opioids but without becoming intoxicated. If the drug is abused, naloxone prevents buprenorphine from binding to the brain’s opioid receptors, so the individual cannot get high and will instead begin experiencing withdrawal symptoms.
Buprenorphine-based medications like Suboxone are vital components of modern opioid addiction treatment. They help people who want to overcome opioid abuse stay focused on the recovery process, which includes behavioral therapy.
When overseen by a medical professional, the dose of Suboxone will slowly taper down until the person is no longer physically dependent on opioids. This process can go as slowly as each individual needs in order to focus on behavioral therapy and maintaining other parts of their life, like employment and family care.
Since Suboxone is such an important drug, it is important that anyone who needs it has access to it.
Is Suboxone Covered by Insurance?
In the United States, healthcare expansions require that health insurance providers offer mental and behavioral health coverage, including treatment for addiction. For example, the Mental Health Parity and Addiction Equity Act (MHPAEA), passed in 2008, requires that health insurers cover the same level of benefits for behavioral conditions like addiction as they do for basic medical or surgical care.
The Affordable Care Act (ACA) requires that all marketplace healthcare plans must cover substance abuse and mental health services like other essential health benefits. The ACA also states that mental health and substance abuse conditions are like other pre-existing conditions. They are no longer grounds for insurance to deny coverage.
Like other types of treatment, though, you must start by getting a diagnosis from a medical professional, who then submits an approval to your insurance provider, called prior authorization. Once this is approved, your doctor can prescribe medications like Suboxone to you, and you can begin your opioid treatment plan.
Currently, only 13 state Medicaid programs list prescription drugs that are part of any MAT for any substance use disorder, including opioid addiction, on a preferred drug list (PDL), which would allow providers to prescribe these substances without a prior authorization. Most states require prior authorization before allowing a prescription for Suboxone.
Prior authorization can take some time, so it is important to stay focused and motivated. Ask your doctor for help remaining abstinent or reducing substance abuse, find a support group near you to get social support for recovery, or ask for a referral to a detox program to get medical oversight while you wait.
Does Medicaid Cover Suboxone Treatment?
If you cannot afford health insurance, even through the ACA Marketplace, you may qualify for Medicaid. This can give you better access to some types of treatment, including MAT for opioid use disorder.
Between 2011 and 2013, all 50 states had buprenorphine/naloxone medications listed on their PDLs, but 48 of those states still required prior authorization. It is important to note that there are medications other than Suboxone that combine these two prescription drugs, so you may receive something that is not specifically Suboxone.
Documentation of behavioral therapy is also required to continue receiving Suboxone or similar medications. Medicaid programs in 21 states require evidence of prescribed therapy alongside MAT. Combining medication and behavioral treatment is considered the best approach to overcoming addiction. It is the foundation of evidence-based treatment programs all over the country.
Some states have established prescription limits for people receiving MAT as part of their recovery program.
- Michigan, Washington, Illinois, and the District of Columbia limit MAT to one year.
- Arkansas, Maine, Mississippi, Montana, Virginia, and Wyoming limit MAT to two years.
- Utah has a three-year MAT limit.
What Are Barriers to Suboxone Access?
Buprenorphine-based medications like Suboxone are very important for people who want to end an addiction to opioids. They are not as restricted as other types of MAT, like methadone, which requires supervised doses taken in a clinic. Suboxone can be taken at home, with regular visits to your doctor to monitor your condition and manage your dose.
More doctors are receiving special training and permission to prescribe buprenorphine. The Substance Abuse and Mental Health Services Administration (SAMHSA) offers a treatment finder so you can locate opioid addiction treatment near you.
A Pew Trust report in 2020 found that insurance billing typically created the greatest barrier to receiving treatment, but some states were exploring low-threshold treatment approaches, which allowed someone interested in buprenorphine medications like Suboxone to receive this MAT in their first doctor’s appointment. Another MAT drug, naltrexone, is widely available with this approach. Lowering barriers to treatment like access and cost means more people can get the help they need.
The cost of Suboxone can depend on your insurance provider, the state you live in, and whether you qualify for Medicaid coverage. However, there are many cost-effective options for treatment.
Buprenorphine/Naloxone (Suboxone). (January 2021). National Alliance on Mental Illness (NAMI).
Does Insurance Cover Treatment for Opioid Addiction? (September 2020). US Department of Health and Human Services (HHS).
Mental Health & Substance Abuse Coverage. Healthcare.gov.
Insurance Rules Can Hamper Recovery From Opioid Addiction. (August 2016). NPR.
Medicaid Coverage and Financing of Medications to Treat Alcohol and Opioid Use Disorders. (2014). Substance Abuse and Mental Health Services Administration (SAMHSA).
Policies Should Promote Access to Buprenorphine for Opioid Use Disorder. (May 2021). Pew Trusts.