Addiction brings with it many hardships for spouses, friends and family: a sense of betrayal, unexpressed anger, grief, fear. Betrayed by the one you want to trust most, closing your mouth when you want to yell, watching your loved one’s life wrenched away, as addiction takes hold. Addiction thrives in darkness.

Only when you usher it into the light, can addiction start to heal. Maybe you’re ready to take that next step, but concerns begin to surface: Will my Highmark insurance help with drug rehab? How much will I need to pay? Will Highmark help with treatment for my child or loved one?

In the following sections, we’ll explore:

  • Government statistics for substance abuse in the U.S.
  • Highmark insurance coverage for adults with Substance Use Disorder (SUD).
  • Coverage for children with substance abuse issues.
  • Prior authorization required for Highmark insurance coverage benefits.
  • Out-of-pocket expenses associated with drug rehab.
  • Where you can turn for support as you take this journey into healing.

Addiction Statistics in the U.S.

Reports from drugabuse.gov show that 1 out of every 15 people on non-prescription opioid pain relief will try heroin within ten years of when the opioid use began. Also, 90% of fatalities from poisoning have been directly linked to drug overdose, and ER visits from prescription medication abuse have skyrocketed to nearly 135% in the past five years.

The Center for Disease Control (CDC) states that a shocking 10% of teens as young as 12 say they have used an illicit substance within the past month. SAMHSA, the government body keeping up with U.S. addiction trends, reports that:

  • 7.7 million people meet the criteria for a co-existing mental disorder, along with chemical dependency.
  • 20 million people in the U.S. meet the criteria for Substance Use Disorder (SUD).
  • 1 in every 12 people in the U.S. struggles with addiction to drugs or alcohol.

Based on this information, the chances of you facing addiction at some point in your life is very high. Knowing how Highmark insurance can help, will empower you on this journey to recovery.

Highmark Insurance Coverage for Adults

In compliance with the Affordable Care Act of 2010, all insurance companies are required to cover, at least in part, drug and alcohol treatment services. Because addiction is now medically recognized as a brain illness, it is seen more as a priority.

Healing from addiction begins with healing the body. The body of an addict has been assaulted at the deepest level, and requires detoxification to purge itself of toxicity and regain healthy functioning.

Most Highmark insurance plans cover medically supervised detox services in an approved detox facility. During detox, medical staff will monitor withdrawal symptoms and address any need for detox medication.

Withdrawal symptoms are usually very uncomfortable and sometimes painful, so it is helpful to have professionals near who can help you know what to expect. The detox medications that Highmark will cover vary depending on your plan. While some plans pay for 100% of the medications, others may just offer to pay a portion of the costs.

Highmark insurance typically covers, in part or in full:

  • Detox services and medical supervision
  • Inpatient treatment
  • Outpatient programs, usually with group, family and individual sessions
  • Relapse prevention programs
  • Individual, group, and family therapy

Usually, inpatient treatment facilities have programs for 28 to 45 days. But some programs can last as long as a year. The amount Highmark will cover depends on the medical necessity of each program, its length, and your individual insurance plan.

While outpatient treatment may be less expensive, studies have proven that inpatient treatment significantly decreases the chances of relapse. If you or someone you love is struggling with addiction, it is highly recommended that you complete inpatient treatment first before moving into an outpatient recovery program.

Most Highmark insurance plans provide an 80% co-insurance for inpatient rehab, but some plans will cover 100%. Highmark may even cover out-of-state residential rehabs in full or in part, based on your individual plan. Highmark typically covers out-of-network services at 50%.

If you’re interested in trying out a program with an intervention considered “experimental,” you can choose to pay for the additional intervention yourself. Highmark will usually cover the remaining services as explained in your health insurance coverage binder.

Highmark Insurance for Rehab for Children

Highmark coverage for children can be similar to the coverage for adults, including:

  • detox services
  • in-patient treatment
  • day treatment during the school day
  • outpatient programs
  • relapse prevention programs
  • individual, group, family therapy

It is important to speak with your insurance provider or check your Summary of Benefits to find out exactly what they are willing to pay for your child. Remember that a “child” is often considered as such under insurance coverage up until he or she is 21 years old. Check your policy for additional information.

Prior Authorization for Addiction Treatment

Prior authorization is meant to act as a cost-saving element by having the insurance agree to pay for a particular intervention before treatment begins. Many addiction procedures require prior authorization, and you’ll want to find out which ones are required for your particular plan.

Out-of-pocket Expenses Associated with Drug Rehab

These costs can include:

  • Deductibles
  • Co-payments
  • Separate fees

With Highmark insurance plans, you’ll probably be responsible for at least 15% of the entire treatment. Your Summary of Benefits should let you know what your responsibility will be.

The amount covered by each plan varies greatly, depending on the amount of the deductible and whether or not you have met your deductible for the calendar year. Your deductible will reset each year.

Most treatment facilities offer a payment plan on a sliding scale, taking into consideration your income level and ability to pay for care.

Where You Can Turn For Support

We at Adrugrehab.org know that it can feel intimidating sifting through your insurance’s fine print. For this reason, we provide a free, 24/7 national helpline staffed with licensed counselors to answer all of your questions and concerns. We offer you confidential referrals to some of the best treatment facilities your insurance will cover. Pick up that phone, and let us help you take that brave next step today!