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. 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. 010% - 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. 010% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological testing 010% - After deductible Not Covered Methadone maintenance treatment $40 60 Not Covered Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 010% - 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. 010% - 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. 010% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological testing 010% - After deductible Not Covered Methadone maintenance treatment $40 45 Not Covered Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 010% - 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. 030% - 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. 030% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological testing 030% - After deductible Not Covered Methadone maintenance treatment $40 65 Not Covered Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 030% - 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. 020% - 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. 020% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological testing 020% - After deductible Not Covered Methadone maintenance treatment $40 30 Not Covered Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 020% - 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 30 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. 020% - 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. 020% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological testing 020% - After deductible Not Covered Methadone maintenance treatment $40 45 Not Covered Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 020% - After deductible Not Covered