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TRICARE Policy Manual 6010.60-M, April 1, 2015
Medicine
Chapter 7
Section 3.18
Medication Assisted Treatment (MAT)
Issue Date:  June 13, 2017
Revision:  C-13, November 15, 2017
1.0  DESCRIPTION
MAT for a diagnosed Substance Use Disorder (SUD) is a holistic modality for recovery and treatment that employs evidence-based therapy, including psychosocial treatments and psychopharmacology, and Food and Drug Administration (FDA)-approved medications as indicated for the management of withdrawal symptoms and maintenance.
2.0  POLICY
2.1  MAT is covered for the treatment of SUDs from both institutional and individual professional providers. However, certain forms of MAT for treatment of opioid use disorder (e.g., administration of methadone) are regulated by the Department Of Health and Human Services’ (DHHS’) 42 CFR 8.12, the Center for Substance Abuse Treatment (CSAT), and the Drug Enforcement Administration (DEA), along with individual state and local regulations (see Section 3.17). Some MAT services may also be used to treat SUDs other than opioid use disorder (e.g., Naltrexone extended release injectable as a commonly prescribed MAT for the treatment of alcohol use disorder).
2.2  Opioid use disorder may be treated on an outpatient basis with FDA approved products by qualified, licensed physicians, Nurse Practitioners (NPs), and Physician Assistants (PAs). Depending on the medication prescribed, a valid physician waiver, or NP/PA waiver (respectively), issued under the Controlled Substances Act, as amended by the Drug Addiction Treatment Act of 2000 (21 United States Code (USC) 823(g)(2)), and verified through Substance Abuse and Mental Health Services Administration (SAMHSA) may be required. If required, the qualified physician, NP, or PA must be registered with the DEA to dispense controlled substances and in possession of an assigned DEA special identification number. See https://www.samhsa.gov/medication-assisted-treatment/physician-program-data/treatment-physician-locator for a list of all SAMHSA recognized providers.
2.3  In all cases, medical and psychological necessity must be determined by diagnostic criteria as described in the current edition of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) before MAT is started.
2.4  MAT reimbursement is covered in the TRICARE Reimbursement Manual (TRM), Chapter 7, Section 5, and Chapter 13, Section 2.
2.5  Individual providers of MAT shall bill for their services using normal Evaluation & Management (E&M) codes. Provision of the MAT pharmaceutical, when administered via Office-Based Opioid Treatment (OBOT), can be found under the TRICARE Pharmacy Benefit (TRICARE Operations Manual (TOM), Chapter 23). For MAT pharmaceuticals typically self-administered, see TRM, Chapter 1, Section 15.
3.0  EXCLUSION
The programmed use of physical measures, such as electric shock, alcohol, or other drugs as negative reinforcement (aversion therapy) is not covered, even if recommended by a physician. Note that Antabuse is not considered a medication used as aversion therapy.
4.0  EFFECTIVE DATES
4.1  November 21, 2013, for MAT provided in a Substance Use Disorder Rehabilitation Facility (SUDRF) only.
4.2  October 3, 2016, for MAT services provided outside of a SUDRF.
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