Medicare Part D covers prescribed medication, and Suboxone is usually covered if a person has this plan.
Medicare covers Suboxone and other drugs when they are medically necessary for the treatment of opioid dependence.
A person with original Medicare parts A and B may get this coverage through the purchase of a Part D plan, which provides prescription drug benefits.
If someone has Medicare Advantage, the alternative to original Medicare, they may receive coverage of Suboxone, depending on their plan. Many plans include prescription drug benefits, but not all of them do.
This article looks at Suboxone, how Medicare provides coverage, out-of-pocket costs, as well as a program that helps with the costs for people with a low income.
It also examines additional medication and other treatments for substance use disorders, along with the associated expenses.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Suboxone is a combination of two medications:
Buprenorphine reduces withdrawal effects when a person stops using opioid drugs, such as heroin.
Naloxone blocks the effects of opioids, such as feelings of wellbeing, that can lead to misuse.
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- slowed breathing
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Aside from Suboxone, Medicare covers other medications for substance misuse. Some are a combination of two drugs similar to Suboxone, while others are single drugs, such as Subutex.
A drug that is an exception to Medicare’s coverage is methadone.
Part D limits coverage to drugs that may be dispensed only upon a prescription, so it covers methadone for the treatment of pain, but not for the treatment of opioid dependence.
If a doctor determines that a person needs Suboxone, they may get coverage in two different ways.
Original Medicare and Part D
Original Medicare is composed of Part A, hospitalization insurance, and Part B, medical insurance. Because the two parts only cover prescription drugs that meet specific criteria, a person must purchase a Part D plan to ensure Suboxone is covered.
Each Part D plan has a formulary, which is a list of covered medications. A policy may include Suboxone under its brand name list, or it may include the generic version of the medication. Some plans may cover neither the brand name nor generic drug, while other plans may cover both.
Before buying a Part D plan, a person may wish to check its formulary.
Medicare Advantage, also known as Part C, is the alternative to original Medicare. Policies still cover parts A and B benefits. However, many plans offer to include prescription drug coverage, which would likely include Suboxone.
The costs of Suboxone under Part D or Part C may depend on factors, such as whether a person uses an in-network pharmacy, and whether an individual gets the brand name or generic version.
In addition to the cost of the drug, someone with a Part D or Part C plan has other expenses. These include:
- monthly premiums
- annual deductibles
If a person with Part D has a low income, they can apply for the Extra Help program, which assists with premiums, coinsurance, and deductibles.
When someone qualifies, the most they would pay for Suboxone in 2020 is $8.95 for the name brand and $3.60 for the generic version.
Although Medicare does not have a separate benefit category for substance use disorder, it covers a full range of services for it when a doctor considers treatment necessary.
Coverage is available for a screening and early intervention program, in addition to inpatient and outpatient treatment.
Part A covers inpatient treatment in a psychiatric or general hospital.
Part B covers many services, including:
- psychiatric evaluation
- ongoing testing
- group and individual psychotherapy
- medication management
- diagnostic tests
- family counseling
- partial hospitalization
Medicare Advantage plans also cover all of the above services of parts A and B.
As of January 1, 2020, if a person with opioid use disorder is part of an opioid treatment program (OTP) that is approved by Medicare, they pay nothing for the services. The Part B deductible may still apply.
If an individual receives the services in a hospital, in a hospital outpatient center or outpatient department, there may be additional costs to pay, such as a copayment or coinsurance.
Each part of Medicare has out-of-pocket costs.
The Part A costs include:
- $1,408 deductible for each benefit period
- 0% coinsurance for the first 60 days of each benefit period
- $352 coinsurance for days 61–90 of each benefit period
- $704 coinsurance for day 91 and beyond for each lifetime reserve day
A benefit period starts the day a person enters the hospital and ends the day after someone has been out of the hospital for 60 consecutive days.
In addition, an individual may have a 20% coinsurance for mental health services received in a hospital, such as doctor visits.
Part B costs include:
- $144.60 monthly premium
- 20% coinsurance
- $198 annual deductible
Medigap is Medicare supplement insurance that helps with parts A and B out-of-pocket costs. A person with original Medicare is eligible to purchase a plan.
Medicare Advantage (Part C)
As with the costs associated with prescription drugs, Part C has expenses related to substance abuse treatment. These include monthly premiums, deductibles, coinsurance, and copays. Costs vary among plans.
Medicare covers Suboxone, which is a combination of two different drugs, to treat opioid dependence. The cost depends on several factors, such as whether a person takes the generic or name brand version of the medication.
A person may receive coverage through either original Medicare with a Part D plan or through a Medicare Advantage plan that includes prescription drug benefits.
Aside from Suboxone, Medicare covers a broad range of interventions for substance use disorder. These include screening, along with inpatient and outpatient treatment.