Buprenorphine (Subutext® or Suboxone®), when administered by a certified physician for the treatment of opioid addiction, is a covered benefit for all plans. Physicians who provide treatment with buprenorphine must be authorized by the Drug Enforcement Agency, as mandated under the Drug Addiction and Treatment Act of 2000.
Physicians who are not authorized to treat with buprenorphine may refer a patient to a practitioner who is certified to prescribe and dispense this medication. Certified physicians are obliged to follow established protocols to ensure correct reimbursement for services related to the administration of buprenorphine.
Billing Codes and Claims Submission
Induction, the initial administration of medically monitored buprenorphine, is considered ambulatory detoxification. The proper code for billing is H0014. Certified physicians are limited to three covered induction sessions for each patient. The induction phase of buprenorphine treatment requires prior approval from our Mental Health and Substance Abuse Services department for all plans, except Medicaid. Instructions for obtaining prior approval are in the Mental Health and Substance Abuse Services chapter of our Provider Manual. Claims for induction submitted without prior approval will be denied.
Once a patient has moved into the stabilization and maintenance phase of treatment, certified physicians may bill each visit using the medication management code H0016. Ongoing medication management does not require prior approval.
We remind you that members may not be billed for any services related to buprenorphine treatment, except for applicable copayments or coinsurances.
If you have questions about finding a network chemical dependency program for your patient, locating a certified prescriber of buprenorphine for opioid detoxification, the use of buprenorphine, requesting prior approvals, resources or any issues concerning this treatment, please call the mental health services number on the back of the member's ID card.