Original Medicare covers opioid treatment programs (OTPs) for opioid use disorder (OUD) from Part B. The program must be government-certified and accredited by an independent, government-approved accrediting body.
Opioid use disorder (OUD) is a severe medical condition that can affect people psychologically and physically.
Help is available from many healthcare professionals, clinics, and facilities, with some offering OTPs.
Medicare covers eligible treatments for OUDs. However, if you choose an OTP, you may have fewer out-of-pocket costs.
For an OTP to be eligible for coverage through Medicare, it must be Substance Abuse and Mental Health Services Administration (SAMHSA) certified and have accreditation from a SAMHSA-approved body.
If you receive Medicare-approved OTP services from a facility or healthcare professional enrolled in Medicare, you will not typically have to pay any copayments. However, you must pay the Part B deductible for OTP supplies and some medications.
If you receive the same services through a doctor or another healthcare professional, you must pay the 20% Part B coinsurance after you’ve paid the $257 deductible.
If you’re eligible for both Medicare and Medicaid, you will pay $0 for the services you receive through your state Medicaid program.
If you have a Medicare Advantage plan, you will have the same coverage rules as Original Medicare. However, you may have network restrictions based on your plan type.
Medicare covers different services under its OTP benefit, including:
- Food and Drug Administration (FDA)-approved medications, including opioid agonists like methadone and opioid antagonists like naltrexone
- substance misuse counseling, including individual and group sessions
- periodic assessments
- intensive outpatient programs
- peer recovery help services
- toxicology tests
- referral services
- coordinated care
Original Medicare Part B will cover some of the prescription medications you may be given. However, you may need a Part D prescription drug plan for others.
If you have a Medicare Advantage plan, your plan must include drug coverage for some medications to be covered.
Anyone with OUD is eligible for an OTP, and doctors
The Centers for Disease Control and Prevention (CDC) states that healthcare professionals should confirm a diagnosis of OUD using a
You may also require blood or urine screenings that check for opioids and assess whether you are at risk of addiction.
Seeking help for addiction can feel daunting or even scary, but several organizations are there to help.
If you believe that you or someone close to you is displaying signs of addiction, you can contact the following organizations for immediate help and advice:
- SAMHSA: 800-662-4357 (TTY: 800-487-4889)
- 988 Suicide & Crisis Lifeline: 988
Below are some common questions about OUD and OTP treatment services.
Yes, both Original Medicare and Medicare Advantage plans pay for eligible costs relating to the diagnosis and treatment of OUD.
Medicare Part D prescription drug plans also cover the costs of some OUD medications.
Out-of-pocket costs may apply, and depending on their plan, you may have to visit in-network doctors and facilities.
In May 2023, the Food and Drug Administration (FDA) approved Brixadi (buprenorphine) extended-release injections to treat moderate to severe OUD.
Brixadi (buprenorphine) is available in either a weekly or monthly injection. Which one a doctor gives you will depend on whether you are new to the medication.
Research from 2023 confirms that the “gold standard” evidence-based medication treatment for OUD is methadone, buprenorphine, or naltrexone.
Opioid treatment programs are purpose-driven treatment plans for OUD.
OTPs typically involve a combination of different therapies, including talking therapies, prescription medications, periodic assessments, and peer support.
If you have Original Medicare, Part B covers opioid treatment programs (OTPs) in full if you have opioid use disorder (OUD) and meet eligibility requirements. People with Medicare Advantage plans have the same coverage but may need to visit in-network doctors or healthcare facilities.
If you have OUD, you can recover, and help is available through your healthcare team, Substance Abuse and Mental Health Services Administration (SAMHSA) at 800-662-4357, or through the 988 Suicide & Crisis Lifeline at 988.