Does Horizon Blue Cross Blue Shield of New Jersey Cover Adderall and Prescription Drug Rehab?

Yes, Horizon Blue Cross Blue Shield of New Jersey commercial plans generally cover treatment for substance use disorders, including addiction to Adderall, other prescription stimulants, ketamine and sleeping pills. New Jersey also has one of the strongest state addiction-coverage laws in the country, which limits prior authorization for in-network treatment on many plans. Whether that law applies to you depends on how your plan is set up, so it is worth checking before you choose a program.

New Jersey's substance use disorder law in plain terms

New Jersey passed P.L. 2017, Chapter 28, to make it easier to get into addiction treatment quickly. According to the law's text and the New Jersey Department of Banking and Insurance (DOBI), for plans it covers:

• Unlimited in-network benefits. Plans must cover inpatient and outpatient substance use disorder treatment at in-network facilities when prescribed by a licensed physician, psychologist or psychiatrist.
• No prior authorization at the start. For the first 180 days of treatment in a plan year, the plan cannot require prior authorization or similar up-front approval when the clinician finds the care medically necessary.
• The first 28 inpatient days. No concurrent or retrospective review during the first 28 days of an inpatient stay. The treating physician decides medical necessity.
• After day 28. Concurrent review can begin, but no more often than every two weeks. If the plan decides continued inpatient care is no longer needed, it must give written notice within 24 hours, and the person can appeal.
• Programs and outpatient visits. Intensive outpatient and partial hospitalization have similar early protections, and outpatient visits are protected from concurrent and retrospective review for the first 180 days.
• Access. Facilities must notify the plan of an admission within 48 hours. If no in-network facility is available right away, the plan must make an exception so admission can happen within 24 hours.

After the initial 180-day period, plans can use medical necessity reviews, prior authorization and other utilization management again.

Does the law apply to your Horizon plan?

The law covers health plans issued in New Jersey, including individual, small employer, large group fully insured and HMO plans, and the State Health Benefits Program and School Employees' Health Benefits Program. Two big groups may not be covered by it:

• Self-funded employer plans. Many large employers pay claims themselves and use Horizon only to run the plan. State insurance laws generally do not reach these plans, though federal parity law still does.
• Plans issued outside New Jersey. If your employer is based in another state, a different state's rules may apply.

Your HR department or Horizon member services can tell you whether your plan is fully insured or self-funded.

How Horizon manages behavioral health

Horizon runs its mental health and addiction benefits through Horizon Behavioral Health. Horizon's handbook for State Health Benefits Program HMO members has described how this works:

• No referral is needed to get behavioral health or substance use treatment.
• Covered settings include inpatient, residential, partial hospital, intensive outpatient, outpatient and group treatment.
• Outpatient care generally does not need authorization.
• Substance use decisions use the American Society of Addiction Medicine (ASAM) criteria, a national standard for matching people to the right level of care.
• Addiction treatment facilities need to be accredited or credentialed.

Other Horizon plans may have different rules, so confirm with the behavioral health number on the back of your ID card.

Federal protections still apply

Whether or not the New Jersey law covers your plan, federal rules do. HealthCare.gov confirms that all Marketplace plans must cover substance use treatment as an essential health benefit. The Department of Labor explains that under the federal parity law, deductibles, copays, visit limits and rules like prior authorization for addiction care cannot be stricter than those for comparable medical care. That applies to fully insured and self-funded employer plans alike.

Matching the drug to the right kind of care

If you are unsure how serious things are, our guides on signs of Adderall addiction and signs of sleeping pill addiction can help you put words to what you are seeing.

Checklist before you start treatment

• Call the behavioral health number on your Horizon ID card and ask whether your plan is subject to New Jersey's substance use disorder law.
• Ask whether the program you are considering is in network. The state law's strongest protections apply to in-network facilities.
• Find out your deductible, copay and coinsurance for the level of care recommended.
• If your plan is self-funded, ask which services need prior authorization and who submits it.
• Make sure the program notifies Horizon of the admission promptly.
• Keep notes of every call, including names and reference numbers.

If Horizon limits or denies care

Under the New Jersey law, if a continued inpatient stay is found no longer necessary after the first 28 days, you must get written notice and can request an expedited appeal. For any denial, the Department of Labor notes you can ask for the medical necessity criteria the plan used, file an internal appeal and then seek an external review. For fully insured New Jersey plans, DOBI is the state regulator that handles consumer complaints.

Finding treatment in and near New Jersey

Start with Adderall rehab in New Jersey or stimulant rehab in Newark, and check each program's network status with Horizon. Some families also look across the river at Ambien detox in New York or ketamine rehab in Pennsylvania. Our insurance guides explain how other carriers compare.

If you or someone you love is in crisis or thinking about suicide, call or text 988. In an emergency, call 911.

Sources

• Understanding Your Mental Health and Substance Use Disorder Benefits (U.S. Department of Labor, EBSA)
• Mental Health and Substance Abuse Health Coverage Options (HealthCare.gov)
• How Can Prescription Drug Addiction Be Treated? (National Institute on Drug Abuse)
• Drug Fact Sheet: Ketamine (Drug Enforcement Administration)
• P.L. 2017, Chapter 28 (New Jersey Legislature)
• Bulletin 17-01: Substance Use Disorder Coverage Requirements (New Jersey Department of Banking and Insurance)
• Horizon HMO Member Handbook (New Jersey Division of Pensions and Benefits)

Related guides

• Adderall Addiction: Signs, Risks and Treatment Options
• Vyvanse Addiction: Signs, Risks and Treatment Options
• Ritalin and Concerta Addiction: Signs, Risks and Treatment
• Ketamine Addiction: Signs, Risks and Treatment Options
• Ambien Addiction: Signs, Risks and Treatment Options
• Lunesta and Sonata Addiction: Risks and Treatment

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