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Does Insurance Cover Addiction to Any Prescription Drug?

Does Insurance Cover Addiction to Any Prescription Drug?

Insurance policies typically cover treatment for prescription drug abuse, but the benefits might vary

Clinical studies overwhelmingly confirm that addiction to drugs like clonazepam affects brain circuitry and neural transmissions, and most insurance policies now provide some measure of benefits to treat this progressive disease. Though traditionally associated with illicit drugs like heroin and cocaine, addiction today is just as likely to involve prescription sedatives, stimulants and pain relievers. When people abuse a prescription drug with recognized abuse potential, insurance policies with addiction-related benefits will typically provide treatment benefits. The exact benefits, however, usually depend on the policy purchased, medical necessity and the type of drug abused.

Opioid Painkiller Addiction

Addiction is not all the same, and treatment needs often vary according to the type of substance abused. Consider those addicted to painkillers like OxyContin, Vicodin and Lorcet. When it comes to opioid painkillers, there are several possible considerations including the following:

  • Gradual dosage reductions during detox improve comfort but not safety.
  • Patients with a history of relapse might benefit from opiate replacement therapy.
  • Many opioid addicts have chronic pain issues that should be addressed in other ways.
  • Non-narcotic pain relief options might include chiropractic massage and acupuncture.

Many insurance companies will cover matters of safety but not comfort. In such cases the patient might have to self-pay for a tapered withdrawal. Likewise, the criteria to qualify for opiate replacement or holistic pain management is often more restrictive. The American Society of Addiction Medicine (ASAM) issued a report in 2013 on coverage for opiate replacement programs that highlighted impractical restrictions, excessive documentation requests and evidence that financial savings drive the limitations.

Sedative and Stimulant Addiction

Different considerations are at play for people addicted to prescription sedatives like clonazepam (Klonopin), diazepam (Valium) and alprazolam (Xanax). When it comes to benzodiazepine- and barbiturate-class sedatives, there are several specific concerns including the following:

  • Stopping use too quickly can result in potentially fatal seizures.
  • The relapse rate for benzodiazepine abuse is generally high.
  • Some people mistakenly discount the risks involved in sedative abuse.
  • Sedatives are among the most commonly prescribed drugs.

The insurance company might ask for a higher threshold of proof that an addiction has taken place, though at the same time, it is more likely to approve benefits for gradual dosage reductions.

Prescription stimulants like methylphenidate (Ritalin) and amphetamine-dextroamphetamine (Adderall) can also be complicated because so many people—including students—take the drug for attention-deficit hyperactivity disorder (ADHD). Many amphetamine addicts crush the pills and snort the powder like cocaine or inject dissolved pills like heroin. This type of amphetamine abuse clearly implies addictive behavior, but insurance companies might request more evidence from people who abuse the drug orally.

Health Insurance Benefits for Rehab

The Affordable Care Act (ACA) and the Mental Health Parity and Addiction Equity Act (MHPAEA) significantly expanded and enhanced addiction-related benefits found in most health insurance policies. The ACA even made addiction treatment one of the 10 essential benefits required of all policies on its exchanges. Insurance companies also want to avoid more serious health consequences that might arise from untreated addiction. For example, drug misuse and abuse accounted for 2.5 million medical emergencies in 2011—i.e., approximately eight emergencies per 1,000 population. Half of which involved nonmedical use of prescription drugs. Untreated addiction can also result in physical and mental health problems that get worse the longer the substance abuse continues. At the same time addiction treatment can be expensive, and insurance companies often try to limit expenses. For example, many will approve benefits for part-time outpatient care, but they will only provide inpatient benefits for addicts who relapsed after outpatient treatment.

Going back to the original question, insurance companies typically do not exclude certain prescription drugs like clonazepam associated with abuse, but the criteria necessary to establish an addiction may differ between each drug type. Furthermore, the benefits provided might also differ. When seeking addiction treatment benefits, several steps might help including the following:

  • Ask the family doctor to screen for addiction and mental health issues.
  • Use the potential diagnosis to help establish the medical necessity of treatment.
  • Speak with the insurance company about benefits, limits, criteria and preapprovals.
  • Find out which treatment centers fall within their group of in-network providers.

An HBO website developed in connection with the Addiction series advises potential addicts to request a full clinical assessment of all physical and mental health issues. Once the assessment is complete, take the findings to the insurer and ask what treatments it will cover. In many cases the identification of co-occurring physical and mental health issues might improve the benefits provided for addiction care. Likewise, if the insurance company denies benefits, utilize appeals and independent reviews that might overturn the denial. The Parity Toolkit can help.

Addiction and Insurance Help

When it comes to addiction treatment benefits for addiction to drugs like clonazepam, there is a lot of information to sift through, but our admissions coordinators can help. We are available 24 hours a day to answer questions, provide information and make recommendations. We can also look up insurance policies and explain their benefits as well as discuss options for people without coverage. Our helpline is toll-free, so if you or a loved one struggles with addiction, please call now.