Common use of Opioid Treatment Program (OTP) Clause in Contracts

Opioid Treatment Program (OTP). The Contractor shall provide coverage for the Opioid Treatment Program (OTP) for members receiving services at OTPs. A daily opioid treatment program includes administration and coverage of an FDA-approved opioid agonist or antagonist medication- assisted treatment (MAT) medication, routine drug testing, group therapy, individual therapy, pharmacological management, follow-up examinations, and one evaluation and management office visit every 90 days for the management of patient activities identified in the individualized treatment plan that assist in patient goal attainment, including referrals to other service providers and linking patients to recovery support groups. OTP coverage will include those members as defined by OMPP and approved by CMS. The MCE will be responsible for OTP services provided by the provider type Addictions Provider and the provider specialty OTP as defined in the IHCP Provider Enrollment Type and Specialty Matrix. Coverage of OTP services will be restricted as follows: ▪ Individuals aged 18 and older seeking OTP services must meet the following medical necessity criteria: • Must be addicted to an opioid drug • Must have been addicted for at least one year before admission to the OTP • Must meet the criteria for the Opioid Treatment Services (OTS) level of care, according to all six dimensions of the American Society of Addiction Medicine (ASAM) Patient Placement Criteria ▪ Individuals under the age of 18 seeking OTP services must meet the following medical necessity criteria: • Must be addicted to an opioid drug • Must have two documented unsuccessful attempts at short-term withdrawal management or drug-free addiction treatment within a 12-month period preceding admission • Must meet the criteria for the Opioid Treatment Services (OTS) level of care, according to all six dimensions of the ASAM Patient Placement Criteria ▪ The following individuals are exempt from the one-year addiction requirement: • Members released from a penal institution – If the individual seeks OTP services within six months of release • Pregnant women • Previously treated individuals – If the individual seeks OTP services within two years after treatment discharge Prior authorization (PA) is not required for OTP services. However, providers must maintain documentation demonstrating medical necessity, that the coverage criteria are met, as well as the individual’s length of treatment, in the member’s records.

Opioid Treatment Program (OTP). The Contractor shall provide coverage for the Opioid Treatment Program (OTP) for members receiving services at OTPs. A daily opioid treatment program includes administration and coverage of an FDA-approved opioid agonist methadone or antagonist medication- assisted treatment (MAT) medicationbuprenorphine, routine drug testing, group therapy, individual therapy, pharmacological management, HIV testing, Hepatitis A, B, and C testing, pregnancy tests, Tuberculosis testing, Syphilis testing, follow-up examinations, case management and one evaluation and management office visit every 90 days for the management of patient activities identified in the individualized treatment plan that assist in patient goal attainment, including referrals to other service providers and linking patients to recovery support groups. OTP coverage will include those members as defined by OMPP and approved by CMS. The MCE will be responsible for OTP services provided by the provider type Addictions Provider and the provider specialty OTP as defined in the IHCP Provider Enrollment Type and Specialty Matrix. Coverage of OTP services will be restricted as follows: ▪ • Individuals aged 18 and older seeking OTP services must meet the following medical necessity criteria: • o Must be addicted to an opioid drug • o Must have been addicted for at least one year before admission to the OTP • o Must meet the criteria for the Opioid Treatment Services (OTS) level of care, according to all six dimensions of the American Society of Addiction Medicine (ASAM) Patient Placement Criteria ▪ • Individuals under the age of 18 seeking OTP services must meet the following medical necessity criteria: • o Must be addicted to an opioid drug • EXHIBIT 1 SCOPE OF WORK o Must have two documented unsuccessful attempts at short-term withdrawal management or drug-free addiction treatment within a 12-month period preceding admission • o Must meet the criteria for the Opioid Treatment Services (OTS) level of care, according to all six dimensions of the ASAM Patient Placement Criteria ▪ • The following individuals are exempt from the one-year addiction requirement: • o Members released from a penal institution – If the individual seeks OTP services within six months of release • o Pregnant women • o Previously treated individuals – If the individual seeks OTP services within two years after treatment discharge Prior authorization (PA) is not required for OTP services. However, providers must maintain documentation demonstrating medical necessity, that the coverage criteria are met, as well as the individual’s length of treatment, in the member’s records.

Opioid Treatment Program (OTP). The Contractor shall provide coverage for the Opioid Treatment Program (OTP) for members receiving services at OTPs. A daily opioid treatment program includes administration and coverage of an FDA-approved opioid agonist methadone or antagonist medication- assisted treatment (MAT) medicationbuprenorphine, routine drug testing, group therapy, individual therapy, pharmacological management, HIV testing, Hepatitis A, B, and C testing, pregnancy tests, Tuberculosis testing, Syphilis testing, follow-up examinations, case management and one evaluation and management office visit every 90 days for the management of patient activities identified in the individualized treatment plan that assist in patient goal attainment, including referrals to other service providers and linking patients to recovery support groups. OTP coverage will include those members as defined by OMPP and approved by CMS. The MCE will be responsible for OTP services provided by the provider type Addictions Provider and the provider specialty OTP as defined in the IHCP Provider Enrollment Type and Specialty Matrix. Coverage of OTP services will be restricted as follows: ▪ • Individuals aged 18 and older seeking OTP services must meet the following medical necessity criteria: • o Must be addicted to an opioid drug • o Must have been addicted for at least one year before admission to the OTP • EXHIBIT 1 SCOPE OF WORK o Must meet the criteria for the Opioid Treatment Services (OTS) level of care, according to all six dimensions of the American Society of Addiction Medicine (ASAM) Patient Placement Criteria ▪ • Individuals under the age of 18 seeking OTP services must meet the following medical necessity criteria: • o Must be addicted to an opioid drug • o Must have two documented unsuccessful attempts at short-term withdrawal management or drug-free addiction treatment within a 12-month period preceding admission • o Must meet the criteria for the Opioid Treatment Services (OTS) level of care, according to all six dimensions of the ASAM Patient Placement Criteria ▪ • The following individuals are exempt from the one-year addiction requirement: • o Members released from a penal institution – If the individual seeks OTP services within six months of release • o Pregnant women • o Previously treated individuals – If the individual seeks OTP services within two years after treatment discharge Prior authorization (PA) is not required for OTP services. However, providers must maintain documentation demonstrating medical necessity, that the coverage criteria are met, as well as the individual’s length of treatment, in the member’s records.

Opioid Treatment Program (OTP). The Contractor shall provide coverage for the Opioid Treatment Program (OTP) for members receiving services at OTPs. A daily opioid treatment program includes administration and coverage of an FDA-approved opioid agonist or antagonist medication- medication-assisted treatment (MAT) medication, routine drug testing, group therapy, individual therapy, pharmacological management, follow-up examinations, and one evaluation and management office visit every 90 days for the management of patient activities identified in the individualized treatment plan that assist in patient goal attainment, including referrals to other service providers and linking patients to recovery support groups. OTP coverage will include those members as defined by OMPP and approved by CMS. The MCE will be responsible for OTP services provided by the provider type Addictions Provider and the provider specialty OTP as defined in the IHCP Provider Enrollment Type and Specialty Matrix. Coverage of OTP services will be restricted as follows: ▪ • Individuals aged 18 and older seeking OTP services must meet the following medical necessity criteria: • o Must be addicted to an opioid drug • o Must have been addicted for at least one year before admission to the OTP • o Must meet the criteria for the Opioid Treatment Services (OTS) level of care, according to all six dimensions of the American Society of Addiction Medicine (ASAM) Patient Placement Criteria ▪ • Individuals under the age of 18 seeking OTP services must meet the following medical necessity criteria: • o Must be addicted to an opioid drug • o Must have two documented unsuccessful attempts at short-term withdrawal management or drug-free addiction treatment within a 12-12- month period preceding admission • o Must meet the criteria for the Opioid Treatment Services (OTS) level of care, according to all six dimensions of the ASAM Patient Placement Criteria ▪ • The following individuals are exempt from the one-year addiction requirement: • o Members released from a penal institution – If the individual seeks OTP services within six months of release • o Pregnant women • o Previously treated individuals – If the individual seeks OTP services within two years after treatment discharge Prior authorization (PA) is not required for OTP services. However, providers must maintain documentation demonstrating medical necessity, that the coverage criteria are met, as well as the individual’s length of treatment, in the member’s records.

Opioid Treatment Program (OTP). The Contractor shall provide coverage for the Opioid Treatment Program (OTP) for members receiving services at OTPs. A daily opioid treatment program includes administration and coverage of an FDA-approved opioid agonist or antagonist medication- assisted treatment (MAT) medication, routine drug testing, group therapy, individual therapy, pharmacological management, follow-up examinations, and one evaluation and management office visit every 90 days for the management of patient activities identified in the individualized treatment plan that assist in patient goal attainment, including referrals to other service providers and linking patients to recovery support groups. OTP coverage will include those members as defined by OMPP and approved by CMS. The MCE will be responsible for OTP services provided by the provider type Addictions Provider and the provider specialty OTP as defined in the IHCP Provider Enrollment Type and Specialty Matrix. Coverage of OTP services will be restricted as follows: ▪ Individuals aged 18 and older seeking OTP services must meet the following medical necessity criteria: • Must be addicted to an opioid drug • Must have been addicted for at least one year before admission to the OTP • Must meet the criteria for the Opioid Treatment Services Servic es (OTS) level of care, according to all six dimensions of the American Society of Addiction Medicine (ASAM) Patient Placement Criteria ▪ Individuals under the age of 18 seeking OTP services must meet the following medical necessity criteria: • Must be addicted to an opioid drug • Must have two documented unsuccessful attempts at short-term withdrawal management or drug-free addiction treatment within a 12-month period preceding admission • Must meet the criteria for the Opioid Treatment Services (OTS) level of care, according to all six dimensions of the ASAM Patient Placement Criteria ▪ The following individuals are exempt from the one-year addiction requirement: • Members released from a penal institution – If the individual seeks OTP services within six months of release • Pregnant women • Previously treated individuals – If the individual seeks OTP services within two years after treatment discharge Prior authorization (PA) is not required for OTP services. However, providers must maintain documentation demonstrating medical necessity, that the coverage criteria are met, as well as the individual’s length of treatment, in the member’s records.

Opioid Treatment Program (OTP). The Contractor shall provide coverage for the Opioid Treatment Program (OTP) for members receiving services at OTPs. A daily opioid treatment program includes administration and coverage of an FDA-approved opioid agonist methadone or antagonist medication- assisted treatment (MAT) medicationbuprenorphine, routine drug testing, group therapy, individual therapy, pharmacological management, HIV testing, Hepatitis A, B, and C testing, pregnancy tests, Tuberculosis testing, Syphilis testing, follow-up examinations, case management and one evaluation and management office visit every 90 days for the management of patient activities identified in the individualized treatment plan that assist in patient goal attainment, including referrals to other service providers and linking patients to recovery support groups. OTP coverage will include those members as defined by OMPP and approved by CMS. The MCE will be responsible for OTP services provided by the provider type Addictions Provider and the provider specialty OTP as defined in the IHCP Provider Enrollment Type and Specialty Matrix. Coverage of OTP services will be restricted as follows: ▪  Individuals aged 18 and older seeking OTP services must meet the following medical necessity criteria: • o Must be addicted to an opioid drug • o Must have been addicted for at least one year before admission to the OTP • o Must meet the criteria for the Opioid Treatment Services (OTS) level of care, according to all six dimensions of the American Society of Addiction Medicine (ASAM) Patient Placement Criteria ▪  Individuals under the age of 18 seeking OTP services must meet the following medical necessity criteria: • o Must be addicted to an opioid drug • EXHIBIT 1 SCOPE OF WORK o Must have two documented unsuccessful attempts at short-term withdrawal management or drug-free addiction treatment within a 12-month period preceding admission • o Must meet the criteria for the Opioid Treatment Services (OTS) level of care, according to all six dimensions of the ASAM Patient Placement Criteria ▪  The following individuals are exempt from the one-year addiction requirement: • o Members released from a penal institution – If the individual seeks OTP services within six months of release • o Pregnant women • o Previously treated individuals – If the individual seeks OTP services within two years after treatment discharge Prior authorization (PA) is not required for OTP services. However, providers must maintain documentation demonstrating medical necessity, that the coverage criteria are met, as well as the individual’s length of treatment, in the member’s records.