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500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 03 | 01|2026 POLICY LAST REVIEWED: 11 | 05 | 2025 OVERVIEW The intent of this policy is to provide Opioid Treatment Program (OTP) reimbursement guidelines for Medicare Advantage Products and Commercial Products.
This policy is applicable to Medicare Advantage Products and Commercial Products. MEDICAL CRITERIA Not applicable NOTIFICATION OF ADMISSION Not Applicable POLICY STATEMENT Medicare Advantage Products OTP services are covered when rendered by a certified OTP that is listed on the CMS OTP website. Commercial Products For Commercial members, Methadone is covered at contracted Methadone Clinics. All other Medication Assisted Treatment (MAT) is covered through a combination of pharmacy and professional outpatient prescribing.
COVERAGE Benefits may vary by group or contract. Please refer to the appropriate member Benefit Booklet or Subscriber Agreement for applicable behavioral health benefits/coverage. BACKGROUND Medicare Advantage Products Effective January 1st, 2020, Medicare began covering OTP services rendered to individuals with opioid use disorder at certified and accredited OTP facilities. OTPs must be certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) accredited by an independent, SAMHSA-approved accrediting body, have a Medicare OTP provider NPI, and be listed on the CMS OTP site. BCBSRI covers OTP services for Medicare Advantage, regardless of whether the certified and accredited OTP facility is in or out of network with BCBSRI. OTP services for Medicare Advantage products include medication assisted treatment and other behavioral health services. Medication assisted treatment includes the dispensing/administering of Methadone, Buprenorphine, or naltrexone. Other services include individual and/or group therapy, substance use counseling, and toxicology testing.
Commercial Products BCBSRI covers substance use disorder treatment for Commercial members. Services for Commercial Products may include medication assisted treatment and other behavioral health services. Medication assisted treatment includes the dispensing/administering of Methadone and prescribing of Buprenorphine, or naltrexone. Other services include individual and/or group therapy, substance use counseling, and toxicology testing.
Payment Policy | Opioid Treatment Program

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

CODING Medicare Advantage Products The following codes are covered when filed according to the instructions above. Providers will be reimbursed at an all-inclusive weekly rate.
G0137 Intensive outpatient services; minimum of nine services over a 7-contiguous day period, which can include individual and group therapy with physicians or psychologists (or other mental health professionals to the extent authorized under State law); occupational therapy requiring the skills of a qualified occupational therapist; services of social workers, trained psychiatric nurses, and other staff trained to work with psychiatric patients; drugs and biologicals furnished for therapeutic purposes, excluding opioid agonist and antagonist medications that are FDA-approved for use in treatment of OUD or opioid antagonist medications for the emergency treatment of known or suspected opioid overdose; individualized activity therapies that are not primarily recreational or diversionary; family counseling (the primary purpose of which is treatment of the individual’s condition); patient training and education (to the extent that training and educational activities are closely and clearly related to individual’s care and treatment); diagnostic services (not including toxicology testing); (provision of the services by a Medicare-enrolled Opioid Treatment Program); List separately in addition to code for primary procedure, if applicable) G0532 Take-home supply of nasal nalmefene HCl; one carton of two, 2.7 mg per 0.1 ml nasal sprays (provision of the services by a Medicare-enrolled opioid treatment program); (list separately in addition to each primary code) G0533
Medication assisted treatment, buprenorphine (injectable) administered on a weekly basis; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled opioid treatment program) G0534 Coordinated care and/or referral services, such as to adequate and accessible community resources to address unmet health-related social needs, including harm reduction interventions and recovery support services a patient needs and wishes to pursue, which significantly limit the ability to diagnose or treat an opioid use disorder; each additional 30 minutes of services (provision of the services by a Medicare-enrolled opioid treatment program); (list separately in addition to each primary code)
G0535 Patient navigational services, provided directly or by referral; including helping the patient to navigate health systems and identify care providers and supportive services, to build patient self advocacy and communication skills with care providers, and to promote patient-driven action plans and goals; each additional 30 minutes of services (provision of the services by a Medicare-enrolled opioid treatment program); (list separately in addition to each primary code)
G0536 Peer recovery support services, provided directly or by referral; including leveraging knowledge of the condition or lived experience to provide support, mentorship, or inspiration to meet MOUD treatment and recovery goals; conducting a person-centered interview to understand the patient's life story, strengths, needs, goals, preferences, and desired outcomes; developing and proposing strategies to help meet person-centered treatment goals; assisting the patient in locating or navigating recovery support services; each additional 30 minutes of services (provision of the services by a Medicare-enrolled opioid treatment program); (list separately in addition to each primary code) G1028 Take-home supply of nasal naloxone; 2-pack of 8 mg per 0.1 ml nasal spray (provision of the services by a Medicare-enrolled Opioid Treatment Program); list separately in addition to code for primary procedure G2067 Medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed (provision of the services by a Medicare-enrolled opioid treatment program) G2068 Medication assisted treatment, buprenorphine (oral); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled opioid treatment program) G2069 Medication assisted treatment, buprenorphine (injectable) administered on a monthly basis; bundle including dispensing and/or administration, substance use counseling, individual and group therapy,

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM and toxicology testing if performed (provision of the services by a Medicare-enrolled opioid treatment program) G2073 Medication assisted treatment, naltrexone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled opioid treatment program) G2074 Medication assisted treatment, weekly bundle not including the drug, including substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled opioid treatment program) G2076 Intake activities, including initial medical examination that is conducted by an appropriately licensed practitioner and preparation of a care plan, which may be informed by administration of a standardized, evidence-based social determinants of health risk assessment to identify unmet health-related social needs, and that includes the patient's goals and mutually agreed-upon actions for the patient to meet those goals, including harm reduction interventions; the patient's needs and goals in the areas of education, vocational training, and employment; and the medical and psychiatric, psychosocial, economic, legal, housing, and other recovery support services that a patient needs and wishes to pursue, conducted by an appropriately licensed/credentialed personnel (provision of the services by a Medicare-enrolled opioid treatment program); list separately in addition to each primary code G2077 Periodic assessment; assessing periodically by an OTP practitioner and includes a review of MOUD dosing, treatment response, other substance use disorder treatment needs, responses and patient- identified goals, and other relevant physical and psychiatric treatment needs and goals; assessment may be informed by administration of a standardized, evidence-based social determinants of health risk assessment to identify unmet health-related social needs, or the need and interest for harm reduction interventions and recovery support services (provision of the services by a Medicare-enrolled opioid treatment program); list separately in addition to each primary code
G2078 Take home supply of methadone; up to 7 additional day supply (provision of the services by a Medicare-enrolled opioid treatment program); list separately in addition to code for primary procedure G2079 Take home supply of buprenorphine (oral); up to 7 additional day supply (provision of the services by a Medicare-enrolled opioid treatment program); list separately in addition to code for primary procedure G2080 Each additional 30 minutes of counseling in a week of medication assisted treatment, (provision of the services by a Medicare-enrolled opioid treatment program); list separately in addition to code for primary procedure G2215 Take home supply of nasal naloxone; 2-pack of 4 mg per 0.1 ml nasal spray (provision of the services by a Medicare-enrolled Opioid Treatment Program); list separately in addition to code for primary procedure
G2216 Take home supply of injectable naloxone (provision of the services by a Medicare-enrolled opioid treatment program); list separately in addition to code for primary procedure Commercial Products The following code is covered when filed according to the instructions above. Providers will be reimbursed at an all-inclusive weekly rate. All other OTP services and Medication Assisted Treatment (MAT) are covered through a combination of pharmacy and professional outpatient prescribing. H0020 Alcohol and/or drug services; methadone administration and/or service (provision of the drug by a licensed program) RELATED POLICIES Not applicable PUBLISHED Provider Update, January 2026 REFERENCES Cms.gov, Opioid Treatment Programs (OTP) | CMS

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM

Cms.gov, Billing & Payment | CMS

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This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.

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