Yes, Blue Cross Blue Shield policies cover substance abuse treatment, including inpatient and outpatient rehab, as well as anti-craving medications like Suboxone or Vivitrol.
Though, being covered by insurance doesn’t necessarily mean addiction treatment is free.
Blue Cross Levels of Care Coverage for Substance Abuse
Does Blue Cross cover inpatient rehab?
Yes, Blue Cross Blue Shield covers inpatient rehab when medically necessary.
- The addiction will need to be moderate or severe to necessitate higher-level inpatient care instead of outpatient care.
- It also requires active drug use. Those that are sober wanting to go to rehab to avoid relapse will likely not get inpatient coverage but can get covered for outpatient IOP or MAT services.
Does Blue Cross cover IOP?
Yes, Blue Cross Blue Shield insurance covers Intensive Outpatient Programs (IOP). The insurance provider sets the requirement for IOP at nine hours of group therapy per week.
Blue Cross Coverage FAQ
BlueCross BlueShield insurance covers detox when medically necessary, which depends on the drug of choice. Drugs like marijuana, meth or cocaine are unlikely to get coverage for detox since these drugs do not have the same physical withdrawals as alcohol, benzodiazepines or opioids.
BlueCross BlueShield is the largest health insurance provider in the country and is run by 36 independent organizations. Most look like “Blue Cross Blue Shield of Illinois” or “Blue Cross Blue Shield of Texas”, but some have variations like “Florida Blue” or “Anthem Kentucky.”
All of these are actually different organizations. An addiction provider can be in-network with one territory, but not another even if they are both Blue Cross. Each BlueCross organization can set different services as covered, not covered or require a specific process for coverage.
Mental Health Benefits
Also, some BlueCross policies offer only medical coverage and not mental health. Usually, this is something the policyholder chose because it is cheaper. Mental healthcare coverage is required for addiction treatment.
Blue Cross Substance Abuse Medication Coverage
Does Blue Cross cover Suboxone?
Yes, Blue Cross Blue Shield considers Suboxone a tier 1 or preferred medication. It doesn’t require prior authorization but does have dispensing limits. The medication, as well as the doctor visits and labs should all be covered with BCBS insurance.
Does Blue Cross cover methadone?
Yes, methadone is covered by Blue Cross Blue Shield insurance plans but often requires prior authorization. All forms of methadone are labeled a tier 2 or “non-preferred” medication.ⓘ
It is a common methadone myth that the medication is not covered by insurance. Symetria is in-network with Blue Cross and the insurance company has covered methadone treatment for hundreds of patients here over the last five years as a proven harm-reduction treatment. All other major insruance companies like Aetna, Cigna and United Healthcare cover additions treatments like methadone.
Additional Substance Abuse Medications
Yes, Vivitrol is covered by Blue Cross Blue Shield insurance plans and does not require prior authorization.
Sometimes. It can be a challenge for the provider to prove that Sublocade is “medically necessary” and meets the specific criteria. (Sublocade is much more expensive and less researched than Suboxone).
The requirements and approval rates for Sublocade vary by state, but often include that:
- The opioid addiction must be proven to be moderate or severe.
- The patient must be enrolled in addiction counseling.
It can take 3-4 weeks to get the approval for Sublocade and have the medication shipped.
Yes, Narcan (naloxone) spray is covered and does not require prior authorization. (Symetria also offers Narcan free to the community).
How much does addiction treatment cost with Blue Cross Blue Shield?
While having BCBS insurance tells you that insurance will likely pay something for addiction treatment, it doesn’t tell you how much insurance will pay versus how much you owe.
To understand how much you will owe, you need to know:
1. The deductible, coinsurance and out-of-pocket maximum rates for your policy
You pay until you meet your deductible. This is a set amount you pay for healthcare before insurance companies pay anything. It resets every year. Some plans have no deductible, though the average deductible last year was $1,655. If you hit your deductible with rehab, any future healthcare costs for the year is reduced.ⓘ
Then, you pay coinsurance, which is the percentage of healthcare costs that you share with your insurance company after your deductible — unless your policy covers 100%. For example, if you have a $100 healthcare cost and your plan has 80% coinsurance, you owe $20 coinsurance.
But, you stop paying anything if you hit an out-of-pocket (OOP) maximum and insurance covers 100%. If you’ve been hospitalized or went to inpatient rehab, you likely will owe very little for additional services.
Blue Cross Rates for Addiction Treatment
BlueCross has a wide range of options for deductible, co-insurance and out-of-pocket rates. The employer chooses what rates to offer and the rates impact the monthly cost of your insurance coverage.
- Some Blue Cross Blue Shield policies cover 90% of medical costs, but usually come with the highest payments every month.
- Other policies cover around 60%, but will have a lower monthly payment.
If an employer allows employees to choose between high deductible and low deductible plans, then even two people with a Blue Cross Blue Shield insurance policies from the same employer can owe dramatically different amounts for addiction treatment.
2. The amount you already spent on healthcare this year
Health insurance plans accumulate for one year – usually January to December, but each employer can set its own month for renewal. Health care costs paid during this time count toward your deductible and out-of-pocket maximum.
So, someone who was hospitalized earlier in the year might pay nothing or much less than someone with the exact same policy that has not accumulated any healthcare cost in the year.
3. Whether the provider you choose is in-network
Choosing a provider that is out-of-network with Blue Cross Blue Shield will almost always cost you more.
- If your policy says “HMO”, Blue Cross will likely not cover an out-of-network provider at all.
- A “PPO” policy covers some treatment, but you usually pay a higher deductible and out-of-pocket maximum than if you chose an in-network provider.
Note: Some addiction treatment centers that say they “accept Blue Cross Blue Shield” are actually out-of-network, so it’s best to ask directly or confirm with BCBS directly.
Getting a Cost Estimate
If you give your insurance information to any addiction treatment center, they should provide you with a cost estimate upfront. (Insurance inquiries are 100% confidential, your employer or others on your insurance plan are not alerted when you inquire).
If you’re in Illinois or Texas, you can use the button below to submit your insurance information online.
Blue Cross Blue Shield Subboxone Doctors, Methadone Clinic, IOP Near Me
Blue Cross Blue Shield offers a “Blue Distinction” recognition for the “Substance Use Treatment and Recovery” category.
Using the Blue Distinction search tool on the BCBS website can help you find the best option.
If you aren’t able to locate a provider, you can try to general Find a Doctor search tool on the BlueCross Blue Shield website or call the number on the back of your insurance card to find a provider that is in-network, though likely not meeting the Blue Distinction criteria.
Symetria Recovery holds Blue Distinction status, so if you’re in Illinois or Texas, click a location below to learn more.
Outpatient Rehab Clinics In-Network with Blue Cross
12 Comments
If I take 3 suboxone a day and my bcbs only covers 2 a day do I pay for the other one out of pocket
That is an option, but it would require two separate prescriptions (one for suboxone twice daily, and one for suboxone once daily), and may still cause issues with the pharmacy not allowing you to pay for the 2nd prescription. A better work-around solution is to contact your prescriber and have them prescribe a higher dosage of the Suboxone film and instruct you to take it twice daily. (I.e. if you usually take one 8 mg film of Suboxone three times daily, have your prescriber send in a prescription to take one 12mg film twice daily.) In this situation, your prescriber may need to complete a prior authorization for your insurance company in order for them to cover the full three films per day. Speak to both the prescriber and pharmacist. They will be able to give you more clarification as to why the insurance is only covering 2 of the 3 doses per day and what needs to be done to make an exception. That way, you wont be forced to accept a lower dose of the medication than you need, and you won’t need to pay at an uninsured rate for the remaining medications.
How can I find out if my plan covers methadone treatment?
You can usually look up your coverage on the insurance company’s online portal or call the number on the back of your insurance card to ask. Methadone is covered by all major insurance companies on most plans.
If I have a medical deductible let’s say 5k. If I am on methadone and go to the methadone clinic, does that 5k deductible have to be met before insurance pays for any of my methadone? The methadone is $20 a day. Does insurance pay anything towards the medication before the deductible is met? Thank you.
Hi! Generally, you are responsible for all medical costs until your deductible is met. Once your deductible is met, your insurance begins to pay typically only a portion of your treatment costs. So, the insurance pays 60-80% while you pay the rest. You pay until you’ve reached our out-of-pocket deductible. That’s when insurance should pay 100%.
Hello, not sure if you can answer this…I am wondering if substance use treatment facilities must be contracted with Blue Cross in order to seek reimbursement for services?
If a facility is not contracted with the insurance, it means the facility is out-of-network. You can ask the facility for an itemized bill and submit this to your insurance company to count toward your out-of-network deductible and possible reimbursement. Usually, out-of-network deductibles are separate and higher than in-network. If the plan is an HMO, typically no out-of-network facility is covered.
How much does blue cross blue shield cover medication suboxone and adderall 30 mg