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 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% - After deductible 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 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 Testing 0% - After deductible 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 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. 020% - After deductible 2040% - 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. 020% - After deductible 2040% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological testing Testing 0% - After deductible 2040% - After deductible Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 2040 40% - After deductible Methadone maintenance treatment. $0 0% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 020% - After deductible 2040% - 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) detoxification or residential/rehabilitation per plan year. Residential Treatment Facility Unlimited days for residential mental health and substance use disorder services per plan year. Notification of admission *Preauthorization may be requiredrequired 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. Notification of services *Preauthorization may be requiredrequired 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% - After deductible 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. $0 030 20% - After deductible 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) detoxification or residential/rehabilitation per plan year. Residential Treatment Facility Unlimited days for residential mental health and substance use disorder services per plan year. Notification of admission *Preauthorization may be requiredrequired 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. Notification of services *Preauthorization may be requiredrequired 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% - After deductible 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. $0 030 20% - After deductible 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 2040% - 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 2040% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological testing Testing 0% - After deductible 2040% - After deductible Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 2015 - After deductible 40% - After deductible Methadone maintenance treatment. $0 - After deductible 0% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 0% - After deductible 2040% - 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% - After deductible 20% - After deductible Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 25 20% plus $25 - After deductible Afterdeductible Methadone maintenance treatment. $0 0% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 020% - 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 Testing 0% - After deductible 20% - After deductible Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 20 20% - After deductible Methadone maintenance treatment. $0 0% - After deductible 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% - After deductible 20% - After deductible Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 25 20% plus $25 - After deductible Methadone maintenance treatment. $0 0% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 020% - 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 Testing 0% - After deductible 20% - After deductible Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 50 20% - After deductible Methadone maintenance treatment. $0 0% - After deductible 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 Testing 0% - After deductible 20% - After deductible Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 40 20% - After deductible Methadone maintenance treatment. $0 0% - After deductible 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% - After deductible 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 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 Testing 0% - After deductible 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 Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 0% - After deductible 20% - After deductible