Understanding Carelon Drug Treatment Coverage

Learn about using your Carelon insurance policy to cover substance abuse treatment


Alcohol and Drug Treatment Coverage with Carelon

If you or someone you know is struggling with addiction, having the right insurance coverage can make a significant difference in accessing the necessary treatment.

Carelon Insurance, formerly known as Beacon Health Options, provides coverage for various substance abuse treatment services.

This guide will help you understand the ins and outs of Carelon’s drug treatment coverage to make well-informed decisions about your care, covering essential topics such as network coverage, claims approval, types of plans, deductibles, and hardships.

By familiarizing yourself with your Carelon benefits, you’ll be better prepared to take the first steps toward recovery and a healthier, substance-free future.

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Carelon drug treatment coverage

When considering addiction treatment, it’s essential to understand the advantages and disadvantages of choosing an in-network provider with your Carelon insurance policy. In-network treatment centers have a contractual agreement with Carelon, which often means lower out-of-pocket costs for you.1

These providers have negotiated rates with the insurance company, resulting in reduced copays, coinsurance, and deductibles. However, the trade-off is that you may have limited options when choosing a specific treatment center or location. Researching and ensuring that the in-network facility offers the type of care and services that best suit your needs is crucial.

Information about Carelon Plan Types

Carelon’s HMO plans typically require choosing a primary care physician (PCP) who coordinates your care and refers you to specialists when needed.2

In most cases, HMO plans only cover treatment from in-network providers, except in emergencies.

While HMO plans often have lower monthly premiums and out-of-pocket costs, they offer less flexibility regarding provider choice.

PPO plans offered by Carelon provide more flexibility than HMO plans.

You can generally receive care from both in-network and out-of-network providers, although choosing an in-network provider typically results in lower out-of-pocket costs.

With a PPO plan, you don’t need to select a PCP or obtain referrals to see specialists.

Carelon’s EPO plans blend features of HMOs and PPOs. Like HMOs, EPO plans typically don’t cover out-of-network care except in emergencies.

However, like PPOs, you usually don’t need to choose a PCP or get referrals for specialist care. EPO plans often have lower monthly premiums compared to PPO plans.

Carelon’s POS plans combine aspects of HMO and PPO plans.

You’ll need to select a PCP who coordinates your care, but you can see out-of-network providers if you’re willing to pay higher out-of-pocket costs.

Seeing in-network providers or obtaining a referral from your PCP generally results in lower costs.

Carelon’s HDHP plans feature lower monthly premiums but higher deductibles than other plan types.

These plans can be paired with a health savings account (HSA) to help cover out-of-pocket expenses.

Once you meet your deductible, your plan starts sharing the cost of covered services.

Carelon also offers managed care plans for Medicaid and Medicare beneficiaries.3

These plans are designed to coordinate care and provide additional benefits beyond what’s typically covered by standard Medicaid and Medicare programs.

Eligibility and coverage details vary by state and plan type.

Understanding Policy Terminology

A deductible is the amount you pay for covered health care services before your Carelon insurance plan starts to pay. For example, if your plan has a $1,000 deductible, you must pay the first $1,000 of covered services yourself.

Once you’ve met your deductible, your insurance will share the cost of covered services according to your plan’s coinsurance or copayment requirements. It’s important to note that some plans may have separate deductibles for in-network and out-of-network care, and not all services may be subject to the deductible.

Carelon Approval Process for Treatment

Before beginning addiction treatment, the first step is to verify your Carelon insurance coverage. The treatment center you choose will contact Carelon to confirm your active policy and determine the specifics of your coverage, such as deductibles, copayments, and coinsurance. They will also inquire about any prior authorization requirements for the services you need.

Once your coverage is verified, the treatment center will inform you of any out-of-pocket expenses you may be responsible for, helping you understand what amount you will have to pay (if any) to get treatment. To streamline this process, you can provide your insurance information to the treatment center in advance.

Get Help Paying Your Deductible

File a Hardship With Carelon 

If you struggle to pay your deductible, you can file a hardship with Carelon. A hardship is a situation that prevents you from being able to afford your medical expenses, such as job loss, unexpected expenses, or a severe illness. To file a hardship claim, you must contact Carelon directly and provide documentation of your financial situation. If approved, insurance may reduce your deductible or offer a payment plan to help make your treatment more affordable.

Assistance Programs & Payment Plans 

Many addiction treatment centers offer assistance programs and payment plans to help make treatment more accessible. These programs may include sliding-scale fees based on income, scholarships, or financing options. Some treatment centers may also have relationships with third-party lenders specializing in providing medical expense loans. When considering a treatment center, ask about any available assistance programs or payment plans to help you manage your out-of-pocket costs.

Community Resources & Charitable Organizations

In some cases, community resources and charitable organizations may be able to help you cover your deductible for addiction treatment. These organizations may include local non-profits, faith-based groups, or foundations dedicated to helping individuals access healthcare services. Some organizations may have specific programs to assist with addiction treatment costs, while others may provide more general financial assistance. It’s worth researching local organizations in your area to see if they offer any help with treatment expenses.

FAQs About Using Carelon Benefits to Pay for Alcohol and Drug Treatment

What types of addiction treatment does Carelon cover?

Carelon health insurance offers a variety of services for addiction treatment, with coverage details dependent on your specific plan and geographic location.

Coverage often includes:

  • Detoxification: Assistance during detox to help safely manage withdrawal symptoms.3
  • Inpatient Rehabilitation: Provides therapy, medical care, and support within a residential setting.
  • Outpatient Rehabilitation: Enables treatment while living at home, incorporating therapy and group meetings.
  • Partial Hospitalization Programs (PHP): Offers intensive treatment on a daily basis, serving as an intermediary step between inpatient and outpatient care.
  • Intensive Outpatient Programs (IOP): A less intensive option than PHP, focusing on recovery skills and therapy for a few hours each day.
  • Counseling and Therapy: Access to individual, group, and family sessions to tackle the behavioral challenges of addiction.


Reviewing your Carelon insurance benefits is essential to understand the coverage for different treatment options, including any limitations or prerequisites, and how to utilize these services effectively.

If you need help, our Cornerstone team understands insurance policies and can immediately begin reviewing your benefits once you verify your insurance with us!

Will I need to get pre-authorization for addiction treatment?

In many cases, you will need to obtain pre-authorization from Carelon before starting addiction treatment.

This means that Carelon will review your case to determine if the proposed treatment is medically necessary and covered under your plan.

Your chosen treatment center can typically help you navigate the pre-authorization process.

How much will I have to pay out-of-pocket for addiction treatment?

Your out-of-pocket costs for addiction treatment will depend on your specific Carelon plan.

Factors that can impact your costs include your deductible, copayments, coinsurance, and out-of-pocket maximum.

You can contact Carelon or your treatment center to get a better understanding of your potential out-of-pocket expenses.

What happens if Carelon denies my claim for addiction treatment?

If Carelon denies your claim for addiction treatment, your treatment center will likely file an appeal on your behalf.

The appeals process allows the treatment center to provide additional information and argue why the services should be covered.

If the appeal is successful, Carelon may reverse its decision and provide coverage for the treatment.


lionel estrada LISAC headshot clinical director scottsdale

Lionel Estrada, LISAC


Lionel, our Clinical Director is a Licensed Independent Substance Abuse Counselor (LISAC) with over 4 years at Cornerstone, specializes in addiction and mental health. Trained in EMDR therapy, he employs a trauma-informed, empathetic approach to address the underlying causes of these issues.

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