Anthem Drug Rehab Insurance: Does It Cover Substance Abuse?

Last Updated: June 10, 2020

Anthem insurance is one of the largest providers in the United States and is the biggest for-profit health care company under the Blue Cross Blue Shield banner. Approximately 40 million Americans rely on Anthem Blue Cross rehab insurance coverage should they require it. All people insured through the company need to understand Anthem’s substance abuse coverage.

Does Anthem Cover Drug Rehab?

Yes, Anthem health insurance plans do cover drug rehab and other services related to substance abuse and mental health disorders. Insured individuals can use Anthem rehab insurance at a wide variety of rehabilitation centers.

Anthem insurance plans for rehab can be used with in-network rehabilitation centers, out-of-network facilities, and rehabs that are specifically affiliated with Anthem. If the patient selects an out-of-network facility, they should understand that they will end up paying more than if they selected in-network one. This can make the cost of rehab more difficult to afford and could result in the patient reaching their substance abuse coverage limits sooner.

Types Of Rehab Covered By Anthem

Anthem coverage includes rehabilitation such as:

As such, patients can get the care that best meets their needs. However, they should speak with a healthcare provider in depth before settling on a specific rehab setup, as it could end up the best treatment isn’t the one the patient believes is best.

Covered Services For Substance Abuse Treatment

Being part of Blue Cross Blue Shield, Anthem drug rehab coverage still has differences. When determining what they will and will not cover, Anthem basis their decision on something called “medical necessity.” If something is needed based on a strictly medical point of view, and the need for this medical treatment has been affirmed, Anthem insurance coverage kicks in. If it is outside the preview of medical necessity, it isn’t covered.

Because what is medically necessary varies from person to person, it is not possible to list all services covered by Anthem insurance. However, there are expenses associated with rehab that, in the vast majority of cases, are not covered. These include:

  • Spa services
  • Private rooms
  • Alternative treatments, such as acupuncture
  • Alternative therapies, such as music therapy
  • Executive facilities
  • Housekeeping
  • Food prep
  • Laundry services
  • Yoga

As a result, anyone who uses Anthem Blue Cross rehab coverage for a residential or inpatient facility is likely going to incur additional expenses they need to cover on their own.

health provider offers insurance plan to a family

Anthem Plan Levels

The coverage a person has access to will determine their Anthem substance abuse coverage. The company divides its insurance coverage into four tiers: bronze, silver, gold, and platinum. As long as the patient knows what tier of coverage they have, they will be able to determine their out-of-pocket cost and what services are covered. Below is a chart covering key substance abuse medical benefits and their costs through Anthem based on coverage tier (in-network and out-of-network costs provided are coinsurance after the deductible is met).

Plan Medical Benefits In-Network Cost Non-Network Cost
Bronze Outpatient treatment
Inpatient stay
35% 50%
Silver Outpatient treatment
Inpatient stay
20% 50%
Gold Outpatient treatment
Inpatient stay
20% 50%
Platinum Outpatient treatment
Inpatient stay
10% 50%

Anthem Admission Criteria For Rehab Hospitalization

For an insured individual to have their Anthem insurance rehab coverage, they have to meet the admission criteria established by the company. Even if a primary care physician has written a referral, if the patient fails to meet the criteria, the insurance coverage will not be extended. Anthem looks at three criteria when determining if they will approve coverage:

  • Severity of illness
  • Intensity of Service
  • Continued stay criteria

While exactly what these include will vary between types of rehab options, there are some similarities. Still, before entering a rehab facility, all patients should contact the company for clarification.

severe symptoms of substance abuse

Severity Of Illness

To qualify for coverage, the patient must meet the DSM criteria for the condition they are looking to have treated. For example, to qualify for withdrawal coverage, the patient must meet criteria for a DSM Axis I or ICD-9 Substance Dependence diagnosis. They also must be on a substance that typically necessitates assistance with withdrawal.

Intensity Of Service

This assesses whether or not the service the person is seeking coverage for meets the level of care that their condition needs. For example, if coverage for acute inpatient rehabilitation is being requested, the facility must offer 24-hour care, have the patient seen by a physician at least once per day, and have a plan in place for discharge from the day the patient is admitted.

Continued Stay Criteria

Continued stay criteria determine if the person needs to continue treatment or the treatment can be stopped without significant risk. In most cases, this only asks that progress is being made and the insured person is not yet stable enough for treatment to stop or step down.

Verify Anthem Rehab Insurance And Start Treatment

Anyone who is battling a substance abuse disorder and has Anthem insurance coverage for drug rehab should have hope. Through this coverage, they can access rehabilitation treatment from numerous providers nationwide. Verify insurance coverage and enroll in treatment.


Page Sources

  1. Behavioral Health Medical Necessity Criteria. Anthem Blue Cross and Blue Shield. 2013. https://www11.anthem.com/behavioralhealth/noapplication/f0/s0/t0/pw_e187008.pdf?refer=ahpprovider&state=co.
  2. Laws and Regulations. Substance Abuse and Mental Health Services Administration. 2019. https://www.samhsa.gov/about-us/who-we-are/laws-regulations.

Published on: October 2nd, 2019

Updated on: June 10th, 2020

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