11/13/2024

We use clinical criteria from the American Society of Addiction Medicine’s Treatment for Addictive, Substance-Related, Co-Occurring Conditions when reviewing requests to determine medical necessity.

On Jan. 1, 2025, Blue Cross and Blue Shield of Texas will update our substance use medical necessity criteria for adults from ASAM Criteria 3.0 to ASAM’s new Criteria 4.0. ASAM Criteria 3.0 will continue to be used for medical necessity criteria for adolescents.

The ASAM criteria are designed to support multi-dimensional assessments and treatments. There is a greater emphasis on the need for integrated care, addressing both the mental and physical health disorders present in patients with addictions.

If you have further questions, please call the member services number on the member’s benefit card.

As a helpful resource, learn more about ASAM’s Treatment for Addictive, Substance-Related, Co-Occurring Conditions.

The American Society of Addiction Medicine is an independent company that has contracted with Blue Cross and Blue Shield of Texas to provide utilization management support for members with coverage through BCBSTX. BCBSTX makes no endorsement, representations or warranties regarding third-party vendors and the products and services offered by them.

This is for informational and educational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider, nor is the information presented intended to replace or supersede any requirements set forth in your contract with BCBSTX. Physicians and other health care providers should use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment.