Are you or a loved one struggling with addiction? You’re ready to get help but you’re wondering: Does Blue Cross cover rehab? How much will I have to pay?

SAMHSA, the government organization responsible for tracking addiction data in the US, reports that:

  • Over 20 million adults suffer from substance abuse disorder or SUD
  • That’s nearly 1 in 12 adults in the US
  • 7.7 million adults suffer from a combination of a mental disorder and substance abuse

According the CDC, the Centers For Disease Control, a staggering 10% of people 12 and up have used illegal drugs in the past month. Addiction can start early. And without treatment, it carries into adult life.

Given these statistics, chances are that you’ll be faced with either seeking treatment or helping someone seek treatment at some point in your life. Understanding what insurance covers will help  the one suffering get the best care possible.

Let’s explore the following:

  • What kinds of treatments are involved in drug and alcohol rehab
  • What Blue Cross Blue Shield covers
  • What, if any treatments, require prior authorization
  • What if any restrictions might there be

We do want to share up front that all coverage is dependent on your individual plan.  Additional restrictions may apply.

While we can’t call this your final source of truth, we will provide you with lots of helpful information regarding BCBS coverage. If you need additional help understanding what your policy covers, working through financial challenges or locating effective treatment options, our compassionate team is here to help when you call our free, confidential helpline.

Identifying your BCBS Rehab Insurance Network

We’ll start with identifying if you have a network you must stay within to qualify for coverage. A network is a group of doctors and facilities who work together as a team to provide you with care.

If you have an HMO plan then you are likely limited to a select group of providers. Before you choose a provider of rehab services, you’ll want to see who’s in your network.

Going outside the network could cost you more or may not be covered at all.

Determining Your Out Of Pocket Costs

This is how much you’ll pay of your own money even if the insurance covers the treatment.

If your plan has a deductible, then you will need to meet it before coverage begins.

Some plans will also have a co-pay, where insurance pays a certain percent and you pay a certain percent. The most common BCBS copay will be 80/20, which means insurance pays 80% and you pay 20%.

There will also be a maximum out of pocket. This is the maximum amount that you must pay before BCBS pays for the rest of the year at 100%.

Prior Authorization Requirements for Rehab Insurance Coverage

Blue Cross requires prior authorization for many substance abuse services including inpatient rehab. Your plan’s specific authorization requirements will be included in your policy.

What Does Blue Cross Blue Shield Typically Cover

Diagnosis includes a visit or visits to the doctor, during which tests will be run and discussions will be had to determine the severity of the addiction and best way to get the sufferer well. The doctor will sign a doctor’s order (prescription) for you to receive treatment.

Blue cross does cover the diagnosis stage of the rehab process.

Most Blue Cross plans cover Medical Detox, a treatment that allows a person to eliminate the substance from their system under the close supervision of medical professionals.

The majority of BCBS plans cover inpatient rehab with a prior authorization. Some plans offer an unlimited stay as long as you pay the co-pay. Others will limit the number of days covered. In inpatient rehab you remain full time in a controlled environment.

Inpatient care may be in an acute hospital setting — what we traditionally think of as a hospital stay — or in residential treatment program, which is intended to feel more like a home setting and may even allow visits from family later in the stay.

Blue Cross also covers Outpatient or Partial Hospitalization for those suffering from substance abuse, which may include intensive outpatient treatment, counseling, psychiatric care and other treatments.

Regarding medications, you will need to review your formulary.

Drug replacement therapy, which involves swapping a dangerous drug  with a better controlled drug and then slowly lowering the dosage, is covered.

Methadone maintenance, during which the dosage is not being lowered, and is used long term to prevent cravings,  is not covered by BCBS.

Relapse prevention is an important part of the recovery process that may last years or decades. BCBS typically covers unlimited counseling visits for those recovering from addiction.

Getting Help With Insurance Questions

Your policy is the source of truth for determining what is covered by your individual plan. Adrugrehab.org is committed to helping those suffering find effective treatment and lasting recovery from their addiction. When you call our free confidential helpline, you’ll speak with compassionate and knowledgeable professionals who will answer your questions and help you and your loved one get on the healing path.