Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40% - After deductible Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible Chiropractic Services In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible Dental Services - Accidental Injury (Emergency) Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Dental Services- Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 2...
Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient Hospital Unlimited days at a general hospital or a specialty hospital including withdrawal management (detoxification) per plan year. Residential Treatment Facility Unlimited days for residential mental health and substance use disorder services per plan year. Notification of admission may be required. 0% - After deductible Not Covered Outpatient or intermediate care services - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Notification of services may be required. 0% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible Not Covered Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. 0% - After deductible Not Covered Methadone maintenance treatment. 0% - After deductible Not Covered Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 0% - After deductible Not Covered
Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Outpatient or intermediate care services* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40% - After deductible Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 0% - After deductible 40% - After deductible
Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible Outpatient or intermediate care services* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% 20% - After deductible Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 20% - After deductible Methadone maintenance treatment - one copayment per seven day period of treatment. $30 20% - After deductible Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 0% - After deductible 20% - After deductible
Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient Hospital Unlimited days at a general hospital or a specialty hospital including withdrawal management (detoxification) per plan year. Residential Treatment Facility Unlimited days for residential mental health and substance use disorder services per plan year. Notification of admission may be required. 0% - After deductible 20% - After deductible Outpatient or intermediate care services - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Notification of services may be required. 0% - After deductible 20% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% 20% - After deductible Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 20% - After deductible Methadone maintenance treatment. $0 0% - After deductible Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 0% - After deductible 20% - After deductible
Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. $750 Not Covered Outpatient or intermediate care services* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. $15 Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing $15 Not Covered Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $15 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. $15 Not Covered Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 0% - After deductible Not Covered
Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient* - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. 0% - After deductible Not Covered Outpatient or intermediate care services* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. 0% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological testing 0% - After deductible Not Covered Methadone maintenance treatment $40 Not Covered Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 0% - After deductible Not Covered
Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient* - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. 0% - After deductible 20% - After deductible Outpatient or intermediate care services* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. 0% - After deductible 20% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological testing 0% 20% - After deductible Methadone maintenance treatment $40 20% - After deductible Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 0% - After deductible 20% - After deductible
Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 10% - After deductible Not Covered Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 10% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 10% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $25 Not Covered Methadone maintenance treatment - one copayment per seven day period of treatment. $25 Not Covered Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 10% - After deductible Not Covered
Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. *Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible
