Harvard Pilgrim Insurance Coverage for Detox, Addiction, & Mental Health Treatment

Cost Of Detox, Addiction Or Mental Health Treatment With Harvard Pilgrim

It’s normal to worry about the costs of substance use treatment, even when you have insurance. Knowing the possible out-of-pocket costs can help you prepare for each step of your treatment.

This section shows what Harvard Pilgrim covers and what you can expect to pay yourself. These costs vary based on your plan, where you get treatment, and how long you need it. There are resources available to help you get care if you’re struggling to afford it.

• Deductibles and Out-Of-Pocket Costs
  You may need to pay a certain amount out of pocket before Harvard Pilgrim will fully cover your treatment. This is called a deductible, and the amount varies between plans. Harvard Pilgrim’s yearly deductibles typically range from as low as $1,500 for an individual plan to over $7,500 for some family plans. Harvard Pilgrim covers more of your treatment costs after you’ve met your deductible. However, you still may need to reach your out-of-pocket maximum for the year before your treatment is covered in full.
• Coinsurance and Copays
  After you reach your deductible, your plan may include coinsurance for your services if you haven’t met your out-of-pocket maximum yet. Coinsurance means you cover a percentage of your treatment costs yourself. That percentage varies between plans, provider tiers, and treatment types, but it often ranges from 20% to 50%.For some plans and outpatient services, you’ll pay a copay. Instead of a percentage, this is a fixed amount you pay every time you receive a specific service. For example, when you go to outpatient therapy, you might pay a $25 copay for each session, and it’s the same every time.If you’ve met your out-of-pocket maximum, Harvard Pilgrim will often cover 100% of your treatment costs.
• Harvard Pilgrim Detox Costs
  Your detox is usually covered by your plan, but the amount of coverage depends on your plan type, coinsurance, and copays, and where you seek treatment.You’ll pay less out-of-pocket when you go to an in-network treatment center or if you have a lower deductible. A high deductible health plan (HDHP) from Harvard Pilgrim will cost more before your benefits cover your care, while a lower deductible typically comes with higher premiums per month.
• Harvard Pilgrim Addiction Treatment Costs
  Your plan and deductible will determine how much of your substance use treatment costs you’re responsible for. Harvard Pilgrim covers both inpatient and outpatient services to some degree after you’ve met your deductible.Even once you meet your deductible, Harvard Pilgrim likely won’t cover your full treatment costs until you meet your out-of-pocket maximum. Before you start treatment, check your plan and provider tier, and verify your benefits with Harvard Pilgrim and the treatment center to find out your exact costs.
• Therapy Copays
  You’ll usually have a set copay for outpatient therapy sessions. Copays are typically less than coinsurance. With Harvard Pilgrim, a copay for a mental health visit to a therapist or psychiatrist ranges from $0 for your first visit to $25.Harvard Pilgrim also covers telehealth therapy. Those copays are the same as an in-person session.
• Psychiatric Medication Costs
  Harvard Pilgrim organizes medications into 5 tiers. Costs are based on 30-day supplies and are broken up according to generics, brand-name, and specialty drugs:
  • Tier 1: Generics with a $5 copay
  • Tier 2: Preferred brand-names with a $25 copay
  • Tier 3: Non-preferred brand names with a $45 copay
  • Tier 4: Preferred specialty brand names with a $160 copay
  • Tier 5: Non-preferred specialty brand names and other high-cost prescriptions with 20% coinsurance up to $250

  These costs also depend on whether you’ve met your deductible and factors related to your specific plan. You may need to get prior authorization for certain medications.

Harvard Pilgrim In-Network vs. Out-Of-Network

Your costs and coverage depend largely on whether you seek care in-network or not. When you know the difference between in- and out-of-network, you can prepare more accurately for your costs.

• In-network: In-network providers have a contract with Harvard Pilgrim with set rates for care. That means you pay less out-of-pocket for services and are less likely to face unexpected healthcare costs. These providers are usually more affordable for you.
• Out-of-network: Out-of-network providers do not have contracts with Harvard Pilgrim. The out-of-pocket costs for services are more unpredictable, and Harvard Pilgrim usually covers a lower percentage of costs. It may not cover your care with these providers at all, so you have higher bills.

Harvard Pilgrim Networks

Harvard Pilgrim offers different types of plans with their provider networks, and coverage varies among them. The treatment centers covered and out-of-pocket costs depend on your plan and network. Your network also affects whether you need a referral or pre-authorization for your treatment.

Harvard Pilgrim serves Maine, Massachusetts, New Hampshire, Connecticut, and Rhode Island. Before you start treatment, talk to the treatment center to confirm your benefits and what they cover.

ChoiceNet Preferred Provider Organization (PPO)

• Most popular employer-sponsored plans
• No referrals needed for specialist care
• Provides coverage with providers outside of New England
• Covers some out-of-network care

Health Management Organization (HMO)

• Requires you to choose a PCP to coordinate your care
• Referrals are required to see a specialist
• Out-of-network care is typically not covered
• Lower premiums, copays, and deductibles

Limited Network Plans

• Uses a small network of providers
• Requires you to choose a PCP and get referrals for specialist care
• Low premiums, but may have higher deductibles and coinsurance
• Does not usually cover out-of-network care

Tiered Network Plans

• Tier 1 has lower costs and copays
• Tiers 2 and 3 have higher out-of-pocket costs
• Providers are assigned to each tier
• Prioritizes accessible, lower-cost care while still offering flexible options
• Most require referrals for specialists

Low-Cost Provider Plans

• Recommends certain networks (LP providers) for lower costs
• Most don’t require referrals to specialists
• No deductible and lowest copays for certain services, like lab work
• Higher deductibles and coinsurance for non-LP providers

Employer-Specific Plans

• Customizes plans based on group needs
• Offers access to the New England Network, allowing for national urgent care access
• Coverage varies based on plan type

Virtual Plans

• Doctor On Demand platform provides 24/7 access to providers
• Covers virtual visits, including for mental health
• Prioritizes digital and virtual services
• Does not offer emergency care

Verify Your Harvard Pilgrim Insurance Coverage