Does Insurance Cover Addiction to Any Prescription Drug?

Does Insurance Cover Addiction to Any Prescription Drug?

Insurance coverage may vary depending on the substance, like Xanax, to which a patient is addicted

Health insurance coverage for addiction treatment has improved over the years. Recent improvements include parity laws, which mandate equal coverage for addiction and other health conditions, and the designation of substance abuse treatment as an essential health benefit for policies covered by the Affordable Care Act. Coverage is still not universal, however, and many differences between individual policies exist. Coverage may differ to a degree depending on the substance, like Xanax, to which a given patient is addicted.

Some drugs are considered more potentially addicting than others. Canada’s Centre for Addiction and Mental Health explains that addiction is most likely to occur when a substance produces a marked contrast between the drug-free and altered state. Factors that contribute to a drug’s addiction risk include a rapid onset of effects, the ability to produce powerful euphoria, short duration of action and the potential for tolerance and withdrawal.

Although the risk level may vary, both the latest version of the Diagnostic and Statistical Manual of Mental Disorders (the DSM-5) and the International Classification of Disease (the ICD 10) acknowledge the possibility of disorders related to a wide range of substances. The DSM-5 acknowledges alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics, anxiolytics, stimulants, tobacco and other or unknown substances. The ICD 10 contains a similar list which also mentions tobacco and volatile solvents and like the DSM contains an open-ended reference to “other psychoactive substances.”

Insurance Coverage and the Determination of Medical Necessity

There are many factors that influence insurance coverage. These include network considerations, pre-certification requirements and caps on the number of treatment days allowed. Beyond the basics spelled out in a policy description, however, decisions are generally based on the determination of medical necessity.

The definition of medical necessity can be very fluid and subjective. A publication on medical necessity by the Department of Health and Human Services notes that there is no federal definition of the term and that only about one-third of US states have regulations addressing the issue. Generally the final determination of medical necessity is made by the insurer, not a medical professional.

How Standards of Care May Differ Depending on the Substance of Abuse

Although they have a large degree of discretion, many insurers do base their determination of medical necessity on guideline, such as those developed by the American Society for Addiction Medicine. Factors often considered include generally recognized standards of care and patient safety. These may vary to a degree depending on the substance to which individuals are addicted like Xanax. Ways in which coverage may vary depending on the drug include the following:

  • Detox – Detoxification, often known simply as detox, is the first stage of addiction treatment. During detox patients undergo withdrawal symptoms while being monitored and kept as comfortable as possible. Drugs differ in the kind of withdrawal symptoms they produce and the degree of medical risk associated with detoxing from them. For this reason insurance coverage may vary depending on the substance involved. Whether inpatient or outpatient detoxtreatment is indicated may be considered as well as the number of days of treatment covered.
  • Types of treatment covered – Although there are a very large number of potential addiction treatment approaches, not all have been empirically tested for every type of addiction. The Substance Abuse and Mental Health Services Administration maintains a National Registry of Evidence-based Programs and Practices containing more than 330 interventions for addressing substance abuse and mental health. If a given intervention has been tested on patients addicted to stimulants, for example, but not to benzodiazepines, it is possible that an insurer could decline to cover it for a patient addicted to Xanax.
  • Medications – In a publication on principles of effective substance abuse treatment, the National Institute on Drug Abuse notes that medications can be very useful for many patients, especially when combined with counseling. They report that patients addicted to opiates or opioids may receive methadone, buprenorphine or naltrexone. Those with an alcohol addiction may be treated with naltrexone, acamprosate or disulfiram. It is possible for patients with other addictions to be prescribed medications on an off-label basis, but insurers may decide not to cover them.

Addiction has both physical and psychological aspects. Occasionally people will become psychologically addicted to drugs or other substances not thought to be psychoactive. In these cases insurance may cover treatment under another diagnosis such as compulsive or impulse control disorder.

We Can Help You Find Answers

If you are curious about your treatment options for addiction to drugs like Xanax and your insurance coverage, we can help you find answers to your questions. Our toll-free helpline is available 24 hours a day and staffed with caring and knowledgeable consultants. We can check your insurance coverage for you if you wish at no cost or obligation and can help you identify treatment programs that meet your needs. Call now, and let us walk beside you on your journey to health and freedom.

Are you ready to seek treatment?

If you are ready to beat a Xanax addiction and start a new life in recovery then we can help. We have admission counselors standing by 24 hours a day to take your email, live chat request, or phone call to get you in the addiction treatment center that best fits your unique & specific needs.