First Medical Health Plan Coverage for Alcohol & Drug Rehab

First Medical Health Plan is a health insurance company that covers people in Puerto Rico. They’ve been in operation since 1977. If you live in Puerto Rico, you may have an employer sponsored health plan through them.

If you’re a government employee, you may also get your health benefits through them. You can also sign up for their plans as an individual. In recent years, they’ve become one of four government health plan providers for the territory. The government health plan is also known as Plan Vital and includes Medicaid.

Does First Medical Health Plan Cover Addiction Treatment?

Many First Medical plans cover mental health and substance use treatment. They may cover services like inpatient and partial hospitalization as well as standard outpatient treatment.

Notably, some of their private plans limit you to one detox episode per year for a maximum length of 45 days. You’ll need to check the details on your specific plan before you commit to treatment.

Their provider network has several hospitals that may be able to give you inpatient drug treatment. Keep in mind you might need to get prior authorization before going. If your primary care provider refers you, they may be able to get the prior authorization for you. You may also be able to get it from the emergency room.

Does First Medical Health Plan Cover Methadone & Suboxone (MAT)?

First Medical plans generally cover all the medications that are used to treat opioid addiction and alcohol misuse, including methadone and suboxone. If MAT is the right treatment for you, you’ll have to get your daily medication dose at a clinic while participating in evidence based treatment there.

The FDA approved medication used in MAT helps manage cravings so that you can avoid relapses and even overdose during treatment. This allows you to focus on recovery and lay a solid foundation for your future. Over time you’ll taper off the medication support so you can live fully substance free.

Make sure to review your specific plan to find out the coverage details before you start treatment.

What Are First Medical Health Plans?

Some of First Medical’s plans are PPO plans. PPO stands for preferred provider organization. In this type of plan, you get the best coverage if you stay in their provider network, but you do have the freedom to see a provider who is outside their network. Your individual plan will specify what they will cover if you go out of network.

Their Plan Vital offering functions like a Health Maintenance Organization (HMO). They require you to stay within their network. You can check online to see if a provider is in their network. You also have to get a referral from your primary care provider for specialist care, but not for your mental health providers.

As long as your mental health providers are part of their network, you can see them without a referral.

First Medical plans are available for government employees, individuals, and families. Private companies can also get insurance plans to offer their employees.

Where Does First Medical Health Plan Operate?

First Health’s network has providers you can see throughout the island of Puerto Rico. This is true of First Health’s private plans as well as their government sponsored plans through Plan Vital.

In the past, if you had a Plan Vital plan you would have to stay within a region of the island. This is no longer true. Regions were eliminated in 2021 when Plan Vital started allowing you to pick a company to manage your benefits.

With First Medical plans, you’re free to get your care in any part of Puerto Rico where you can find a provider from their network.

What Inpatient Rehab Does First Medical Health Plan Cover?

Before going to inpatient treatment you’ll first need a clinician to assess that it’s the right level of treatment for you. First Medical will use the information from that assessment to make a determination about coverage.

If your provider determines that you need medically supervised inpatient detox you can expect to be at a facility between three and ten days. With inpatient detox trained professionals monitor how you’re doing with withdrawal. They will work to prevent and treat symptoms as they occur which may include medication assisted treatment (MAT).

Once you’re through detox your provider may want you to go to inpatient or residential rehab. While there you can expect to participate in a structured program where you learn relapse prevention skills. Residential rehab usually lasts 30 to 90 days.

What Outpatient Addiction Treatment Does First Medical Health Plan Cover?

First Medical covers a few different types of outpatient treatments that might be right for you. You might step down to outpatient treatment from residential rehab but it’s also possible to go straight into one of these outpatient treatment types. Doing so would depend on how stable your medical situation is and your home environment among other factors.

Partial hospitalization programs (PHPs) usually expect you to be there the full day up to five days a week. The programming is a lot like residential rehab where you’re in groups most of the day learning and practicing skills that help you with recovery. The difference is you go home at the end of the day and usually on the weekend too.

Intensive outpatient programs (IOPs) are usually held for a few half days each week. The programming is otherwise similar to partial hospitalization. This option is a good one if you have time commitments like work or caregiving that you need to have time during the week to attend to.

General outpatient care meets around once a week and provides ongoing support as you practice your new habits and solidify your recovery.

Does First Medical Health Plan Cover Methadone & Suboxone (MAT)?

When providers use medication to treat your addiction, that’s sometimes called medication assisted therapy, or MAT. There are a few different ways to treat you with MAT.

One type of MAT uses medications to help you withdraw from the drug you’re addicted to safely and as comfortably as possible. This strategy is common in residential detox settings.

If you’re addicted to opioids or alcohol MAT may be used as a maintenance therapy to help you stay stable during treatment. Depending on the maintenance drug that’s most appropriate for you, this strategy will allow you to minimize or skip withdrawal. The medications that addiction specialists prescribe for opioid maintenance are methadone and Suboxone.

First Medical has methadone clinics and Suboxone providers included in their network listings. They may cover that treatment for you if it’s the right treatment for your addiction.

Does Addiction Treatment Need to Be In Network?

Whether you have to stay within First Medical’s provider network to get treatment depends on the specifics of your plan. While some plans may allow you to go out of network you will have to pay more if you use that option. Before going out of network consider taking note of how your copay and deductible and out of pocket maximum might change if you do.

How to Verify Coverage With First Medical Health Plan

First Medical gives you a few ways to verify coverage of a specific provider or facility. You can pick up the phone and call First Medical’s customer service line or you can log in to your account online and check that way. This will give you details about your plan and provider network.

You can also call the treatment center you’re interested in seeing and ask them to check if they take your insurance. With any of these options use your exact plan name and not just the name of the company to check your coverage since First Medical has different networks for different plans.