We Accept Most Insurance. Please Call to Verify Yours.
June 15, 2024
If you or a loved one is struggling with a substance use disorder, you’ve probably heard about the fact...
Read More
Anthem Pathway Insurance Coverage
Anthem Pathway is a popular Anthem Blue Cross Blue Shield insurance option, offering HMO and POS coverage to patients across the United States. The plan is an Affordable Care Act plan available in some U.S. states with further individual designations per state. E.g., Anthem Pathway Guided Access serves Georgia, Anthem Pathway Essentials serves Colorado, Pathway X serves California, etc. If you have this personal insurance and want to attend drug and alcohol rehab, the good news is, you have a wide network to choose from for coverage. However, as a relatively small program with limited coverage across each state it’s in, you’ll have to shop around to ensure you’re going to an in-network provider.
This does mean that Anthem Pathway Insurance many require more research than some other providers. However, with a bit of care, you can easily get coverage for your drug and alcohol rehab with this insurance provider.
Does Anthem Pathway Insurance Cover Drug & Alcohol Treatment?
Yes! Anthem Pathway insurance is required by law to offer coverage for drug and alcohol treatment. In fact, it’s an Affordable Care Act plan, meaning that it fully conforms to the laws and guidelines set forth under the ACA. This means that it treats substance use disorders as temporary disabilities and offers coverage for both inpatient and outpatient treatment. It also treats preexisting conditions, meaning you’ll still get coverage from this provider even if you start the insurance plan after being diagnosed with a substance use disorder.
However, the type of treatment available to you and the amount covered will depend on your plan. Pathway plans all offer three tiers of bronze, silver, and gold. In addition, they are either HMO, PPO, or POS plans. Both can offer benefits but will impact your actual costs. Therefore, you’ll always want to refer to your actual plan and what it includes.
What Types of Drug & Alcohol Treatment Does Anthem Pathway Cover?
Anthem Pathway will cover most types of drug treatment, providing you have a local provider in network. Here, the network will be your largest limiting factor.
In theory, Anthem Pathway covers:
Inpatient Treatment
You can seek out residential care to get coverage of up to 90% of costs after deductibles with your Anthem Pathway plan. This means that if you have a rehab center in your specific Pathway plan, you can go to treatment to get coverage to the amount listed by your plan. Anthem does not limit based on type of treatment providing your service provider is in-network.
Outpatient Treatment
You can attend a wide range of in network outpatient treatment centers for intensive care, partial hospitalization, or even long-term treatment. Coverage starts at 40% minus your deductible and goes up to 90% minus your deductible.
Detox
If you have a doctor’s reference, you can opt to attend a detox clinic or center. The clinic must be in network. However, if you’re referred on an emergency basis, your Anthem Pathway insurance plan will cover costs. This means you can get partial or all coverage in some scenarios even if the detox center isn’t in your network. However, it’s still better to choose an in-network clinic.
Medication
Anthem Pathway insurance covers medication and medication assisted treatment plans. However, you’ll get different rates and deductibles based on whether you’re choosing for preferred or generic medication. If you want to reduce rates, talk to your clinic or therapist.
Complimentary Treatment
You can attend any complimentary treatment program in network for Anthem. This includes a range of treatment options but you can typically expect to pay a significantly higher fee and deductible for your treatment. Therefore, most are recommended to stay in-network for treatment.
What Can You Expect to Pay for Rehab with Anthem Pathway?
Anthem Pathway includes over 20 different specific plans including HMO, PPO, and POS plans (POS is a middle ground between PPO and HMO). Here, your requirements and coverage rates will significantly change depending on what you have and where you live. Here, you can look at your card, your health insurance plan, or call Anthem directly. You’ll want to know:
- Your plan and plan number
- What level it is (Bronze, Silver, Gold)
- Whether it’s PPO, HMO, or POS
- If you can go to out of network providers and if so, what the rates are
However, Anthem Pathway is an ACA insurance policy. This means that its costs are relatively predictable. Here, on average you’ll pay:
- Bronze – 40% of total costs
- Silver – 30% of total costs
- Gold – 20% of total costs
- Platinum (sometimes called catastrophic) – 10% of total costs
However, you’ll always have deductibles that kick in first. For example, with the Anthem Silver Pathway Essentials 4000, you can expect:
- $5,800 deductible
- $8,900 out of pocket limit
- Flat-rate of $20 per pharmacy prescription in network and $80 per pharmacy prescription out of network
- 40% coinsurance for rehab services
- Out of network providers are not covered at all
However, with 20+ plans in the Anthem Pathway network, you’ll want to individually check your rates, coverage, and deductibles.
How to Start Drug & Alcohol Treatment with Pathway?
- Contact your primary care doctor to get referrals and to help you find in-network treatment centers
- Contact your rehab center before going to ensure they are in network for Anthem Pathway insurance. Some plans offer no coverage for out of network treatment
- Check if you need precertification. If precertification is required, you must get it.
- If you have a blue card, you must get approval to use the provider before treatment is given. You’ll also need precertification.
- If you’ve been admitted to emergency services, the provider must call your insurance within 48 hours
Depending on your plan, you may or may not need a referral. However, it’s always a good idea to do so.
Getting Started
Anthem Pathway plans can be complicated. Therefore, it’s a good idea to double check by calling Anthem directly, verifying your plan and your coverage, and checking which providers are in network. Often, you’ll have to go through your doctor to get a referral to treatment and your doctor can also help you find an in-network provider.
However, total costs, deductibles, and even whether your plan covers out of network providers will vary significantly, so you’ll always want to double check your plan. Good luck getting treatment.
