Does Anthem Cover Suboxone?

Suboxone is a brand-name formulation of buprenorphine and naloxone. Anthem plans typically place Suboxone in a “nonpreferred products” category, meaning your doctor will need to fill out extra paperwork before you can fill out your prescription.[1]

Anthem plans cover generic forms of buprenorphine/naloxone, including types administered in films to dissolve in your cheek.[1] A generic form of the medication does not require extra steps.

Anthem uses a tiered system when determining how much participants pay for their medications. As a nonpreferred product, Suboxone is in Tier 3. It’s much more expensive than generic versions, which are in Tier 1.[2]

Does Anthem Cover Suboxone Treatment?

Anthem treats Suboxone as a non-preferred product, meaning patients may have a harder time getting claims accepted and their costs covered when compared to generic alternatives.[1] This generally means that a patient should talk to their provider about buprenorphine/naloxone SL film, which is the generic equivalent of Suboxone and a preferred product under Anthem’s policies.

Practically speaking, this means that while Suboxone coverage may be somewhat complicated and technically possible, patients can more easily get a generic and chemically more or less identical medication covered as standard. If you and your prescriber keep this in mind, this difference won’t meaningfully affect most people’s treatment.

How Much Does Suboxone Cost?

Based on this sample summary of benefits provided by Anthem, Suboxone is treated as a non-preferred brand drug and generally requires prior authorization, placing it at Tier 3 in terms of covered prescription drug costs.[2] 

Most people can simply use the generic buprenorphine-naloxone instead, which would be treated as a Tier 1 medication. In most cases, Tier 1 substances are generic drugs that come with a lower price tag.

This cost comparison can help you understand the differences.[2]

How to Get Brand-Name Suboxone With Anthem

If you’re determined to use brand-name Suboxone, you must obtain something called prior authorization.

For years, insurance companies have used prior authorization procedures to control costs. Doctors kick off the process by filling out a form that outlines the following information:

• The member’s name and identifying information
• The prescriber’s name and identifying information
• The name of the drug and dosage required
• Proof of medical testing, such as pregnancy confirmation and OUD diagnosis
• Clear documentation about why the member can’t use a generic

Anthem’s form typically looks like this, and when it’s complete, doctors must fax it to Anthem headquarters. Officials review the information, and if it’s approved, they allow the doctor to write a prescription for Suboxone. That prescription will be clearly marked as approved, and you’ll leave the pharmacy with the brand-name drug.

Anthem’s Coverage of MAT 

When determining which drugs might be covered by your plan and at what tier, you can consult the formulary (also called the drug list) associated with your plan.[3] If a treatment option is evidence-based and accepted by the FDA, it is generally going to be on this list. For example, methadone is a Tier 2 medication, as it is an accepted, evidence-based MAT for opioid use disorder (OUD). 

Is Addiction Treatment Covered Beyond MAT?

If you want in-network substance misuse resources, Blue Cross Blue Shield Association, which Anthem is a part of, provides an easy-to-use tool to see what’s available in your area.[4]

Generally speaking, your plan should help provide you with coverage for evidence-based addiction treatment, including counseling and inpatient treatment stays, if you use in-network resources. If you choose an out-of-network provider, coverage is going to vary based on how your plan handles out-of-network costs.

Checking Your Coverage With Anthem

If you want to get estimates on your medical costs and check your coverage, you can use Anthem’s Find Care tool by logging in with the account associated with your plan.[5] This tool isn’t available for all Anthem plans, but you can also check coverage by directly contacting your insurance company and providing them with information about the treatment option you’re seeking to get covered.