TRICARE Coverage for Addiction and Substance Use Treatment

There is a particular kind of pressure that comes with a military ID and an addiction you cannot keep hiding. You may be worried about your career, your command, or your family's coverage all at once. The practical question underneath all of it is simple: what will TRICARE actually pay for, and what do you have to do first? The short answer is that TRICARE covers substance use disorder treatment that is medically or psychologically necessary, and the rules for getting there depend on whether you are the service member or a family member, and which TRICARE plan you have.

What TRICARE covers

TRICARE's covered services for substance use disorder treatment include:

• Inpatient services, both emergency and nonemergency
• Management of withdrawal symptoms (detoxification)
• Residential substance use disorder rehabilitation
• Partial hospitalization programs (PHP)
• Intensive outpatient programs (IOP)
• Medication-assisted treatment (MAT), including office-based opioid treatment
• Opioid treatment programs
• Mental health therapeutic services

TRICARE does not cover aversion therapy or unproven treatments, and there is a separate list of mental health exclusions worth checking if you are considering an unusual or experimental approach.

How you get care depends on who you are

This is the part that causes the most confusion, so it helps to be concrete.

Active duty service members must get all mental health care at a military hospital or clinic when possible. To see a TRICARE-authorized civilian provider, an active duty member needs a referral and pre-authorization, even when enrolled in TRICARE Prime Remote. The primary care manager coordinates those referrals.

Everyone else follows a looser set of rules. Under TRICARE Prime, most beneficiaries do not need a referral or pre-authorization for outpatient visits with a network psychiatrist or psychologist, but referrals are required for psychoanalysis and for outpatient substance use disorder therapy. Inpatient care requires a referral and pre-authorization from the regional contractor. Under TRICARE Select and similar plans, most mental health appointments do not need referrals, but inpatient care still requires pre-authorization, and psychoanalysis and some substance use disorder therapy require referrals.

TRICARE For Life is a special case: it follows Medicare's rules for mental health care until those Medicare benefits are exhausted.

Detox, residential, PHP, and IOP: what authorization looks like

The clearest source is TRICARE's West region contractor, TriWest, whose published requirements state the following for the West region:

• Acute psychiatric hospitalization, including high-risk detoxification, is covered when medically or psychologically necessary. Emergency admissions do not require prior authorization, but facilities should notify TriWest within 24 hours and no later than 72 hours after admission. Non-emergency admissions require prior authorization.
• Substance use disorder rehabilitation facilities are covered for all ages when medically necessary for substance use disorder and dual diagnosis treatment, providing ASAM Level 3.5 and 3.7 care. Emergency detoxification admissions do not require prior authorization; non-emergency detoxification and all rehabilitation admissions do.
• General residential treatment centers are only covered for children and adolescents under 21. Residential care for adults, including active duty, is not a covered benefit except for substance use disorder treatment when medically necessary.
• Partial hospitalization programs (ASAM Level 2.5 for substance use) and intensive outpatient programs (ASAM Level 2.1) require prior authorization for all beneficiaries.

One detail worth knowing: TRICARE states that network and non-network providers who submit claims for services that required prior authorization without getting it receive a 10 percent payment reduction, and that penalty may not be passed on to the beneficiary. In other words, a provider's paperwork mistake should not become your bill.

Requirements vary by region and plan and can change, so confirm the specifics with your regional contractor for your exact situation.

Medication-assisted treatment

TRICARE covers medication-assisted treatment, which combines FDA-approved medications with evidence-based therapy to manage withdrawal and support recovery, and it covers opioid treatment programs. Prior authorization is required for office-administered medication-assisted treatment for all beneficiaries, and for opioid treatment program services.

If you are considering methadone or buprenorphine, ask the treating provider which authorization applies and who is submitting it, because these are among the services that will be reviewed before care begins.

A first step you can take today

If you are not sure where to start, call your regional contractor's behavioral health line and ask two things: what level of care is covered for your situation, and what authorization the facility needs to submit. If you are an active duty member, loop in your primary care manager early, because the referral has to come from that channel.

If you would rather talk through your options first, call (800) 653-9376. The call is free to you, the referral service is paid for by treatment providers, and it is confidential. SAMHSA's National Helpline (1-800-662-4357) is another free, confidential option available around the clock, and the Veterans Crisis Line is available by calling 988 and pressing 1.

If you are in crisis right now, call or text 988 for the Suicide and Crisis Lifeline. Call 911 for a medical emergency.

Questions about Tricare Coverage