Common use of Mental Health or Substance Use Clause in Contracts

Mental Health or Substance Use. Disorder 100% of eligible charges after a $50 member copayment per visit for visits for a mental health or substance use disorder. Deductible does not apply. Specialist 100% of eligible charges after a $75 member copayment per visit for visits with a specialist, except for visits for a mental health or substance use disorder. Deductible does not apply. Hospital services: 75% of eligible charges after the deductible. Not covered. XXX covers eligible transplant services that PIC’s medical director or designee pre-certifies and determines in advance to be medically necessary and not investigative but only when the transplant services are received at a designated transplant network provider. Coverage for organ transplants, bone marrow transplants, and bone marrow rescue services is subject to periodic review. PIC evaluates transplant services for therapeutic treatment and safety. This evaluation continues at least annually or as new information becomes available and it results in specific guidelines about benefits for transplant services. You may call PIC at the telephone number listed inside the cover of this contract for information about these guidelines. Benefits, if the transplant meets the definition of an eligible charge, is medically necessary, and not investigative, are available for the following eligible transplants:

Mental Health or Substance Use. Disorder 100% of eligible charges after a $50 25 member copayment per visit for visits for a mental health or substance use disorder. Deductible does not apply. Specialist 100% of eligible charges after a $75 50 member copayment per visit for visits with a specialist, except for visits for a mental health or substance use disorder. Deductible does not apply. Hospital services: 7580% of eligible charges after the deductible. Not covered. XXX covers eligible transplant services that PIC’s medical director or designee pre-certifies and determines in advance to be medically necessary and not investigative but only when the transplant services are received at a designated transplant network provider. Coverage for organ transplants, bone marrow transplants, and bone marrow rescue services is subject to periodic review. PIC evaluates transplant services for therapeutic treatment and safety. This evaluation continues at least annually or as new information becomes available and it results in specific guidelines about benefits for transplant services. You may call PIC at the telephone number listed inside the cover of this contract for information about these guidelines. Benefits, if the transplant meets the definition of an eligible charge, is medically necessary, and not investigative, are available for the following eligible transplants:

Mental Health or Substance Use. Disorder 100% of eligible charges after a $50 40 member copayment per visit for visits for a mental health or substance use disorder. Deductible does not apply. Specialist 100% of eligible charges after a $75 60 member copayment per visit for visits with a specialist, except for visits for a mental health or substance use disorder. Deductible does not apply. Hospital services: 7570% of eligible charges after the deductible. Not covered. XXX covers eligible transplant services that PIC’s medical director or designee pre-certifies and determines in advance to be medically necessary and not investigative but only when the transplant services are received at a designated transplant network provider. Coverage for organ transplants, bone marrow transplants, and bone marrow rescue services is subject to periodic review. PIC evaluates transplant services for therapeutic treatment and safety. This evaluation continues at least annually or as new information becomes available and it results in specific guidelines about benefits for transplant services. You may call PIC at the telephone number listed inside the cover of this contract for information about these guidelines. Benefits, if the transplant meets the definition of an eligible charge, is medically necessary, and not investigative, are available for the following eligible transplants:

Mental Health or Substance Use. Disorder 100% of eligible charges after a $50 45 member copayment per visit for visits for a mental health or substance use disorder. Deductible does not apply. Specialist 100% of eligible charges after a $75 60 member copayment per visit for visits with a specialist, except for visits for a mental health or substance use disorder. Deductible does not apply. Hospital services: 7570% of eligible charges after the deductible. Not covered. XXX covers eligible transplant services that PIC’s medical director or designee pre-certifies and determines in advance to be medically necessary and not investigative but only when the transplant services are received at a designated transplant network provider. Coverage for organ transplants, bone marrow transplants, and bone marrow rescue services is subject to periodic review. PIC evaluates transplant services for therapeutic treatment and safety. This evaluation continues at least annually or as new information becomes available and it results in specific guidelines about benefits for transplant services. You may call PIC at the telephone number listed inside the cover of this contract for information about these guidelines. Benefits, if the transplant meets the definition of an eligible charge, is medically necessary, and not investigative, are available for the following eligible transplants:

Mental Health or Substance Use. Disorder 100% of eligible charges after a $50 125 member copayment per visit for visits for a mental health or substance use disorder. Deductible does not apply. Specialist 100% of eligible charges after a $75 175 member copayment per visit for visits with a specialist, except for visits for a mental health or substance use disorder. Deductible does not apply. Hospital services: 75100% of eligible charges after the deductible. Not covered. XXX covers eligible transplant services that PIC’s medical director or designee pre-certifies and determines in advance to be medically necessary and not investigative but only when the transplant services are received at a designated transplant network provider. Coverage for organ transplants, bone marrow transplants, and bone marrow rescue services is subject to periodic review. PIC evaluates transplant services for therapeutic treatment and safety. This evaluation continues at least annually or as new information becomes available and it results in specific guidelines about benefits for transplant services. You may call PIC at the telephone number listed inside the cover of this contract for information about these guidelines. Benefits, if the transplant meets the definition of an eligible charge, is medically necessary, and not investigative, are available for the following eligible transplants: