Tricare West Insurance Addiction Treatment Coverage

Tricare is one of the largest health insurance providers in the United States and its Tricare West branch covers most of the western United States. Tricare is also one of the most transparent insurance providers out there, offering simple percentage rates for out of network providers. In addition, it covers some 9+ million people across the United States. If you have Tricare for yourself or for your family, you’re probably wondering what your options for addiction treatment are with Tricare West.

Tricare West has a lot to offer for anyone looking for addiction treatment. However, the plan has a significant number of limitations, which means you’ll likely be unable to seek out inpatient care unless you have a reference from a doctor and an emergency situation. Understanding the offerings and what you can get will help you to make the best choices for your health and for your budget as you move into treatment.

Does Tricare West Cover Addiction Treatment?

Yes, all health insurance providers are required by law to offer coverage for substance use disorder treatment (SUD). This is required under the Affordable Care Act also known as Obamacare. However, the amount and the extent to which coverage is offered is not regulated, meaning that many providers like Tricare offer specific stipulations on what they do and do not cover.

For example, Tricare West focuses on offering coverage for outpatient care. Individuals who want to attend an inpatient program require prior authorization. In addition, you may require notifications of when you’re admitted and a notice that this is on an emergency basis.

In addition, Tricare West does not offer coverage for hospital treatment of drug and alcohol abuse or detoxification unless you can show that a hospital setting is medically required.

Therefore, you may have more trouble getting the treatment you want than you would with another provider.

What Types of Substance Use Disorder Treatment Does Tricare West Cover?

In theory, Tricare West covers all types of substance use disorder treatment, including all 5 of the diagnosis related group categories. This means you can get treatment for alcohol or drug abuse with rehabilitation therapy, comorbid or dual diagnosis and complications of substance abuse, and rehab for those without complications.

That works out to:

Essentially, you can generally get the treatment you need with Tricare. However, you will have to ensure you go through the proper channels to get approval and referrals.

What Does Addiction Treatment Costs with Tricare West?

Tricare West has a simple deductible system. In fact, for its premium-based plans, you can expect to pay:

• Tricare Prime – You’ll pay $182 per in network hospital admission and $36 per outpatient visit. You’ll also have a $300 deductible. For services beyond this deductible, you’ll pay a maximum of 50% of the allowable charge.
• Tricare Select – You’ll pay $182 for an in-network visit and $365 for an out of network visit. In addition, if you’re a family member rather than the direct holder, you’ll pay $365 for an in-network visit and $730 for an out of network visit.  You’ll also have a copay of 20% for outpatient visits. For hospitalization, you’ll pay $21.30 per day or $25 per admission (whichever is more) or up to $250 per day or 25% of hospital charge (whichever is less) plus 20% copayment depending on your plan. For out of network treatment, that goes up to $1,112 per day or up to 25% of hospital charge (whichever is less) plus a 25% copayment.

That makes it very straightforward to see what your costs will be – although these costs will still vary depending on the cost of your substance use disorder treatment.

Does Tricare West Allow Out of Network Providers?

All Tricare West plans allow you to seek out an out of network provider. However, you will, on average, pay about 15% more for an out of network provider. In some cases, especially for inpatient services, you could pay significantly more. For example, the rate for an out of network inpatient treatment with Tricare Select Group B can be as high as $1,112 per day plus the 25% copayment. That same treatment with an in-network provider can be as little as $250 per day plus 20% copayment for Group B. Essentially, it’s significantly cheaper to choose an in-network provider so you probably want to opt for that.

Getting Help with Substance Abuse

If you or a loved one is struggling with substance abuse, Tricare West will cover your treatment. However, the amount it covers will depend on your group, your plan, and whether you’re going to an in network provider or not. The best place to start is always your primary care provider, as Tricare West actually charges extra for not having a referral from your primary doctor.

Good luck getting treatment.