Common use of Behavioral Health Services – Mental Health and Substance Use Disorder Clause in Contracts

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. 20% - 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. Preauthorization may be required for services received from a non-network provider. 20% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 20% - After deductible Not Covered Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. $30 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 20% - After deductible Not Covered

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Hospital Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation withdrawal management (detoxification) per plan year. Preauthorization Residential Treatment Facility Unlimited days for residential mental health and substance use disorder services per plan year. Notification of admission may be required for services received from a non-network providerrequired. 2010% - After deductible Not Covered Outpatient or intermediate care services* 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 Notification of services may be required for services received from a non-network providerrequired. 2010% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 2010% - After deductible Not Covered Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 35 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. $30 0 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 2010% - 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. 2010% - After deductible Not Covered Outpatient or intermediate care servicescareservices* - 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. 2010% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 2010% - After deductible Not Covered Medication-assisted treatment - when rendered by whenrenderedby a mental health or substance use disorder provider. $30 20 Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $30 20 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episodecoveredepisode. 2010% - After deductible Not Covered

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Hospital Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation withdrawal management (detoxification) per plan year. Preauthorization Residential Treatment Facility Unlimited days for residential mental health and substance use disorder services per plan year. Notification of admission may be required for services received from a non-network providerrequired. 2010% - After deductible Not Covered Outpatient or intermediate care services* 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 Notification of services may be required for services received from a non-network providerrequired. 2010% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 2010% - After deductible Not Covered Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 45 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. $30 0 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 2010% - 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. 2010% - 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. Preauthorization may be required for services received from a non-network provider. 2010% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 2010% - After deductible Not Covered Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 45 Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $30 45 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 2010% - 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. 200% - 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. Preauthorization may be required for services received from a non-network provider. 200% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 200% - After deductible Not Covered Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 25 Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $30 25 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 200% - 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. 200% - 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. Preauthorization may be required for services received from a non-network provider. 200% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 200% - After deductible Not Covered Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. $30 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 200% - 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. 2010% - After deductible Not Covered Outpatient or intermediate care servicescareservices* - 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. 2010% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 2010% - After deductible Not Covered Medication-assisted treatment - when rendered by whenrenderedby a mental health or substance use disorder provider. $30 Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $30 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episodecoveredepisode. 2010% - After deductible Not Covered

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Hospital Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation withdrawal management (detoxification) per plan year. Preauthorization Residential Treatment Facility Unlimited days for residential mental health and substance use disorder services per plan year. Notification of admission may be required for services received from a non-network providerrequired. 2010% - After deductible Not Covered Outpatient or intermediate care services* 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 Notification of services may be required for services received from a non-network providerrequired. 2010% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 2010% - After deductible Not Covered Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 25 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. $30 0 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 2010% - 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. 20% $300 per admission - After deductible Not Covered Outpatient or intermediate care servicescareservices* - 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. 200% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 200% - After deductible Not Covered Medication-assisted treatment - when rendered by whenrenderedby a mental health or substance use disorder provider. $30 35 - After deductible Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $30 35 - After deductible Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episodecoveredepisode. 200% - 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. 20% $300 per admission - After deductible Afterdeductible 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. 200% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 200% - After deductible Not Covered Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 35 - After deductible Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $30 35 - After deductible Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 200% - 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. 200% - After deductible Not Covered Outpatient or intermediate care services* 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. 200% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 20testing 0% - After deductible Not Covered Medication-assisted treatment - when rendered by whenrenderedby a mental health or substance use disorder provider. $30 20 Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $30 20 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episodecoveredepisode. 200% - 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. 20% - 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. Preauthorization may be required for services received from a non-network provider. 20% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 20% - After deductible Not Covered Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $30 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 20% - 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. 2010% - 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. Preauthorization may be required for services received from a non-network provider. 2010% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 2010% - After deductible Not Covered Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $30 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 2010% - 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. 200% - 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. Preauthorization may be required for services received from a non-network provider. 200% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 200% - After deductible Not Covered Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 20 Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $30 20 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 200% - 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. 200% - After deductible Not Covered Outpatient or intermediate care servicescareservices* - 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. 200% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 200% - After deductible Not Covered Medication-assisted treatment - when rendered by whenrenderedby a mental health or substance use disorder provider. $30 20 Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $30 20 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episodecoveredepisode. 200% - 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. 200% - 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. Preauthorization may be required for services received from a non-network provider. 200% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 200% - After deductible Not Covered Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 25 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. $30 25 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 200% - 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. 2010% - After deductible Not Covered Outpatient or intermediate care servicescareservices* - 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. 2010% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 2010% - After deductible Not Covered Medication-assisted treatment - when rendered by whenrenderedby a mental health or substance use disorder provider. $30 25 Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $30 25 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episodecoveredepisode. 2010% - 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. 2010% - 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. Preauthorization may be required for services received from a non-network provider. 2010% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 2010% - After deductible Not Covered Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 35 Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $30 35 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 2010% - 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. 200% - After deductible Not Covered Outpatient or intermediate care services* 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. 200% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 20testing 0% - After deductible Not Covered Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 20 Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $30 20 Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 200% - 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. 200% - After deductible Not Covered Outpatient or intermediate care services* 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. 200% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 20testing 0% - After deductible Not Covered Medication-assisted treatment - when rendered by whenrenderedby a mental health or substance use disorder provider. $30 0% - After deductible Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $30 0% - After deductible Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episodecoveredepisode. 200% - 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. 200% - After deductible Not Covered Outpatient or intermediate care services* 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. 200% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 20testing 0% - After deductible Not Covered Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 0% - After deductible Not Covered Methadone maintenance treatment - one copayment per seven-seven day period of treatment. $30 0% - After deductible Not Covered Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 200% - After deductible Not Covered