| HMO | Substance Abuse Outpatient |
| Aetna US Healthcare | Covers: Diagnosis, medical treatment, and medical referral services by PCP for the abuse of or addiction to alcohol or drugs.
Cost Sharing: Copayment applies. Excludes: Chronic alcoholism or drug addiction treatment.. |
| Blue Cross Blue Shield | Covered.
Limits: Inpatient and outpatient services, except detoxification, are subject to a $8,000 calendar year maximum and a $16,000 lifetime maximum. Cost Sharing: Copayment applies to each visit |
| CIGNA / Healthsource | Excluded: Unless purchased in a supplemental policy.
With the purchase of a supplemental policy-- Covers: Outpatient substance abuse services provided by Cigna Behavioral Health, Inc., a specialized managed care organization that provides mental health and substance abuse services. Also covers intensive outpatient care. Emergency services are available 24 hours a day. Limits: Outpatient care is the preferred mode of treatment. Coverage is limited to short-term therapy that is medically necessary to provide diagnosis, crisis intervention, and treatment of substance abuse conditions |
| Doctors Health Plan | Excluded: Unless purchased under a supplemental policy. Emergency services are available 24 hours a day. Referral from PCP is not necessary.
Limits: If covered, care must be authorized and referred by Magellan Behavioral Health of North Carolina (1-800-359-2422). Substance abuse services are limited to an annual maximum of $8,000 per member and a lifetime maximum of $16,000. Cost Sharing: Copayments may apply. |
| Generations | Covers: Outpatient care including diagnosis, medical treatment and referral services for alcohol or drug abuse or addiction. Also covers ancillary and detoxification services.
Limits: Benefits, combined inpatient and outpatient, maximum of $8,000 per contract year and $16,000 lifetime. All care must be authorized by Magellan. |
| Optimum Choice | Covers:
Limits: To be covered, treatment must be arranged through appropriate referral by the member’s PCP and must be medically necessary. The condition must also be treatable. Care and treatment are subject to a maximum dollar amount per benefit year ($8,000) and lifetime ($16,000). Cost Sharing: A deductible and coinsurance may apply. |
| PARTNERS | Excluded, unless covered by a supplemental rider.
With purchase of a supplemental rider covers: Outpatient therapy and medication check for short-term evaluation or crisis treatment of alcohol or substance abuse. Includes individual therapy, intensive outpatient therapy and group therapy. Covers methadone treatment when treatment of heroin addiction is covered by the supplemental policy. Limits: All services except for emergencies must be approved in advance by plan’s designated chemical dependency providers. Maximum benefit per member per contract year of $8,000; maximum lifetime benefit per member of $16,000. Cost Sharing: Copayments apply Excludes: Treatment of chronic, non-acute conditions, long-term rehabilitation, vocational rehabilitation, and employment, religious, pastoral and psychic counseling. |
| Coventry/Principal Health Care of the Carolinas | Excluded: Unless purchased in a supplemental policy.
Supplemental policy: Covers: Group and individual treatment for substance abuse Limits: 20 visits per calendar year, 2 group sessions may be substituted for 1 individual session Cost Sharing: 50% coinsurance applies for all substance abuse services |
| Qual Choice | Covers: Covers short-term crisis intervention treatment that is medically or psychologically necessary care and is provided by a network provider. Qual Choice has a special network of substance abuse providers. Under the HMO gatekeeper option (Option 1), you must first call Qual Choice for a referral in order to get services.
Limits: Care and treatment are subject to a maximum dollar amount per benefit year and lifetime. Cost Sharing: A deductible and coinsurance may apply. Excludes: Treatments that are considered experimental such as nutritionally-based therapies for alcoholism and substance abuse, or non-abstinence based substance abuse treatments. Excludes: Nutrition-based therapy for alcoholism or other chemical dependency. |
| The Wellness Plan of North Carolina, Inc. | Covers: Diagnosis and medical treatment.
Limits: Inpatient and outpatient services are subject to a $8,000 calendar year maximum and a $16,000 lifetime maximum. A behavioral health case manager picked by TWP-NC will manage the care. Services must be provided by participating providers. The member may obtain a referral for mental health services by his or her PCP or directly by calling the behavioral health case manager. Excludes: Hypnotic therapy for behavioral modification of smoking, obesity, etc. |
| United HealthCare | Covers: Alcohol or chemical dependency evaluations, crisis intervention, diagnostic evaluation, individual and group therapy services, and intensive chemical rehabilitation. Intensive dependency rehabilitation includes family participation and after-care.
Limits: Covered only when provided by a participating provider. Treatment must be approved in advance by United Behavioral Health. Chemical dependency services are limited to an $8,000 annual maximum and a $16,000 lifetime maximum. Cost Sharing: Copayment may apply. |
| WellPath | Excluded unless covered by a supplemental policy. Most groups purchase the chemical dependency rider.
Covers, with the purchase of a supplemental policy: Residential facilities, social setting programs, day treatment, and other forms of outpatient care for the treatment of chemical dependency. Limits: The participating provider of chemical dependency services must provide and arrange for the provision of services. The covered services are provided in the most cost-efficient setting that is appropriate for the member’s condition. Chemical dependency services are limited to an $8,000 annual maximum and a $16,000 lifetime maximum. Cost Sharing: Copayments apply. |