Common use of Other Outpatient Mental Health and Substance Use Disorder Services Clause in Contracts

Other Outpatient Mental Health and Substance Use Disorder Services. In addition to office visits, Benefits are available for other outpatient services for the diagnosis and treatment of Mental Health and Substance Use Disorders. You can receive these other outpatient services in a facility, office, home, or other non- institutional setting. Other Outpatient Mental Health and Substance Use Disorder Services include, but are not limited to: • Behavioral Health Treatment – professional services and treatment programs, including applied behavior analysis and evidence-based intervention programs, prescribed by a Physician or licensed psychologist and provided under a treatment plan approved by the MHSA to develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism; • Electroconvulsive therapy – the passing of a small electric current through the brain to induce a seizure, used in the treatment of severe depression; • Intensive Outpatient Program – outpatient care for mental health or substance use disorders when your condition requires structure, monitoring, and medical/psychological intervention at least three hours per day, three days per week; • Office-based opioid treatment – substance use disorder maintenance therapy, including methadone maintenance treatment; • Partial Hospitalization Program – an outpatient treatment program that may be in a free-standing or Hospital-based facility and provides services at least five hours per day, four days per week when you are admitted directly or transferred from acute inpatient care following stabilization; • Psychological Testing – testing to diagnose a mental health condition; and • Transcranial magnetic stimulation – a non-invasive method of delivering electrical stimulation to the brain for the treatment of severe depression. Benefits do not include: • Treatment for the purposes of providing respite, day care, or educational services, or to reimburse a parent for participation in the treatment. Benefits are available for inpatient facility and professional services for the treatment of Mental Health and Substance Use Disorders in: • A Hospital; or • A free-standing residential treatment center that provides 24-hour care when you do not require acute inpatient care. Medically Necessary inpatient substance use disorder detoxification is covered under the Hospital services Benefit. Benefits are available for services performed by a Physician, surgeon, or other Health Care Provider to diagnose or treat a medical condition. Benefits include: • Office visits for examination, diagnosis, counseling, education, consultation, and treatment; • Specialist office visits; • Urgent care center visits; • Second medical opinions; • Administration of injectable medications; • Outpatient services; • Inpatient services in a Hospital, Skilled Nursing Facility, residential treatment center, or emergency room; • Home visits; • Telehealth consultations, provided remotely via communication technologies, for examination, diagnosis, counseling, education, and treatment; and • Teladoc primary care consultations. See the Mental Health and Substance Use Disorder Benefits section for information on Mental Health and Substance Use Disorder office visits and Other Outpatient Mental Health and Substance Use Disorder services. Benefits are available for formulas and special food products if you are diagnosed with phenylketonuria (PKU). The items must be part of a diet prescribed and managed by a Physician or appropriately-licensed Health Care Provider. Benefits include: • Enteral formulas; and • Special food products for the dietary treatment of PKU. Benefits do not include: • Grocery store foods used by the general population; or • Food that is naturally low in protein, unless specially formulated to have less than one gram of protein per serving. Benefits are available for the diagnosis and treatment of conditions of the foot, ankle, and related structures. These services, including surgery, are generally provided by a licensed doctor of podiatric medicine. Benefits are available for maternity care services. Benefits include: • Prenatal care; • Postnatal care; • Involuntary complications of pregnancy; • Inpatient Hospital services including labor, delivery, and postpartum care; • Elective newborn circumcision within 18 months of birth; and • Pregnancy termination services. See the Diagnostic X-ray, imaging, pathology, and laboratory services and Preventive Health Services sections for information about coverage of genetic testing and diagnostic procedures related to pregnancy and maternity care. The Newborns’ and Mothers’ Health Protection Act requires health plans to provide a minimum Hospital stay for the mother and newborn child of 48 hours after a normal, vaginal delivery and 96 hours after a C-section. The attending Physician, in consultation with the mother, may determine that a shorter length of stay is adequate. If your Hospital stay is shorter than the minimum stay, you can receive a follow-up visit with a Health Care Provider whose scope of practice includes postpartum and newborn care. This follow-up visit may occur at home or as an outpatient, as necessary. This visit will include parent education, assistance and training in breast or bottle feeding, and any necessary physical assessments for the mother and child. Prior authorization is not required for this follow-up visit.

Other Outpatient Mental Health and Substance Use Disorder Services. In addition to office visits, Benefits are available for other outpatient services for the diagnosis and treatment of Mental Health Conditions and Substance Use DisordersDisorder Conditions. You can receive these other outpatient services in a facility, office, home, or other non- non-institutional setting. Other Outpatient Mental Health and Substance Use Disorder Services include, but are not limited to: •  Behavioral Health Treatment – professional services and treatment programs, including applied behavior analysis and evidence-based intervention programs, prescribed by a Physician or licensed psychologist and provided under a treatment plan approved by the MHSA to develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism; •  Electroconvulsive therapy – the passing of a small electric current through the brain to induce a seizure, used in the treatment of severe depression; •  Intensive Outpatient Program – outpatient care for mental health Mental Health Conditions or substance use disorders Substance Use Disorder Conditions when your condition requires structure, monitoring, and medical/psychological intervention at least three hours per day, three days per week; •  Office-based opioid treatment – substance use disorder maintenance therapy, including methadone maintenance treatment; •  Partial Hospitalization Program – an outpatient treatment program that may be in a free-standing or Hospital-based facility and provides services at least five hours per day, four days per week when you are admitted directly or transferred from acute inpatient care following stabilization; •  Psychological Testing – testing to diagnose a mental health conditionMental Health Condition; and •  Transcranial magnetic stimulation – a non-invasive method of delivering electrical stimulation to the brain for the treatment of severe depression. Benefits do not include: •  Treatment for the purposes of providing respite, day care, or educational services, or to reimburse a parent for participation in the treatment. Benefits are available for inpatient facility and professional services for the treatment of Mental Health Conditions and Substance Use Disorders Disorder Conditions in: •  A Hospital; or •  A free-standing residential treatment center that provides 24-hour care when you do not require acute inpatient care. Medically Necessary inpatient substance use disorder detoxification is covered under the Hospital services Benefit. Benefits are available for services performed by a Physician, surgeon, or other Health Care Provider to diagnose or treat a medical condition. Benefits include: •  Office visits for examination, diagnosis, counseling, education, consultation, and treatment; •  Specialist office visits; •  Urgent care center visits; •  Second medical opinions; •  Administration of injectable medications; •  Outpatient services; •  Inpatient services in a Hospital, Skilled Nursing Facility, residential treatment center, or emergency room; •  Home visits; •  Telehealth consultations, provided remotely via communication technologies, for examination, diagnosis, counseling, education, and treatment; and •  Teladoc primary care consultations. See the Mental Health and Substance Use Disorder Benefits section for information on Mental Health and Substance Use Disorder office visits and Other Outpatient Mental Health and Substance Use Disorder services. Benefits are available for formulas and special food products if you are diagnosed with phenylketonuria (PKU). The items must be part of a diet prescribed and managed by a Physician or appropriately-licensed Health Care Provider. Benefits include: • Enteral formulas; and • Special food products for the dietary treatment of PKU. Benefits do not include: • Grocery store foods used by the general population; or • Food that is naturally low in protein, unless specially formulated to have less than one gram of protein per serving. Benefits are available for the diagnosis and treatment of conditions of the foot, ankle, and related structures. These services, including surgery, are generally provided by a licensed doctor of podiatric medicine. Benefits are available for maternity care services. Benefits include: • Prenatal care; • Postnatal care; • Involuntary complications of pregnancy; • Inpatient Hospital services including labor, delivery, and postpartum care; • Elective newborn circumcision within 18 months of birth; and • Pregnancy termination services. See the Diagnostic X-ray, imaging, pathology, and laboratory services and Preventive Health Services sections for information about coverage of genetic testing and diagnostic procedures related to pregnancy and maternity care. The Newborns’ and Mothers’ Health Protection Act requires health plans to provide a minimum Hospital stay for the mother and newborn child of 48 hours after a normal, vaginal delivery and 96 hours after a C-section. The attending Physician, in consultation with the mother, may determine that a shorter length of stay is adequate. If your Hospital stay is shorter than the minimum stay, you can receive a follow-up visit with a Health Care Provider whose scope of practice includes postpartum and newborn care. This follow-up visit may occur at home or as an outpatient, as necessary. This visit will include parent education, assistance and training in breast or bottle feeding, and any necessary physical assessments for the mother and child. Prior authorization is not required for this follow-up visit.

Other Outpatient Mental Health and Substance Use Disorder Services. In addition to office visits, Benefits are available for other outpatient services for the diagnosis and treatment of Mental Health Conditions and Substance Use DisordersDisorder Conditions. You can receive these other outpatient services in a facility, office, home, or other non- non-institutional setting. Other Outpatient Mental Health and Substance Use Disorder Services include, but are not limited to: • Behavioral Health Treatment – professional services and treatment programs, including applied behavior analysis and evidence-based intervention programs, prescribed by a Physician or licensed psychologist and provided under a treatment plan approved by the MHSA to develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism; • Electroconvulsive therapy – the passing of a small electric current through the brain to induce a seizure, used in the treatment of severe depression; • Intensive Outpatient Program – outpatient care for mental health Mental Health Conditions or substance use disorders Substance Use Disorder Conditions when your condition requires structure, monitoring, and medical/psychological intervention at least three hours per day, three days per week; • Office-based opioid treatment – substance use disorder maintenance therapy, including methadone maintenance treatment; • Partial Hospitalization Program – an outpatient treatment program that may be in a free-standing or Hospital-based facility and provides services at least five hours per day, four days per week when you are admitted directly or transferred from acute inpatient care following stabilization; • Psychological Testing – testing to diagnose a mental health conditionMental Health Condition; and • Transcranial magnetic stimulation – a non-invasive method of delivering electrical stimulation to the brain for the treatment of severe depression. Benefits do not include: • Treatment for the purposes of providing respite, day care, or educational services, or to reimburse a parent for participation in the treatment. Benefits are available for inpatient facility and professional services for the treatment of Mental Health Conditions and Substance Use Disorders Disorder Conditions in: • A Hospital; or • A free-standing residential treatment center that provides 24-hour care when you do not require acute inpatient care. Medically Necessary inpatient substance use disorder detoxification is covered under the Hospital services Benefit. Benefits are available for services performed by a Physician, surgeon, or other Health Care Provider to diagnose or treat a medical condition. Benefits include: • Office visits for examination, diagnosis, counseling, education, consultation, and treatment; • Specialist office visits; • Urgent care center visits; • Second medical opinions; • Administration of injectable medications; • Outpatient services; • Inpatient services in a Hospital, Skilled Nursing Facility, residential treatment center, or emergency room; • Home visits; • Telehealth consultations, provided remotely via communication technologies, for examination, diagnosis, counseling, education, and treatment; and • Teladoc primary care consultations. See the Mental Health and Substance Use Disorder Benefits section for information on Mental Health and Substance Use Disorder office visits and Other Outpatient Mental Health and Substance Use Disorder services. Benefits are available for formulas and special food products if you are diagnosed with phenylketonuria (PKU). The items must be part of a diet prescribed and managed by a Physician or appropriately-licensed Health Care Provider. Benefits include: • Enteral formulas; and • Special food products for the dietary treatment of PKU. Benefits do not include: • Grocery store foods used by the general population; or • Food that is naturally low in protein, unless specially formulated to have less than one gram of protein per serving. Benefits are available for the diagnosis and treatment of conditions of the foot, ankle, and related structures. These services, including surgery, are generally provided by a licensed doctor of podiatric medicine. Benefits are available for maternity care services. Benefits include: • Prenatal care; • Postnatal care; • Involuntary complications of pregnancy; • Inpatient Hospital services including labor, delivery, and postpartum care; • Elective newborn circumcision within 18 months of birth; and • Pregnancy termination services. See the Diagnostic X-ray, imaging, pathology, and laboratory services and Preventive Health Services sections for information about coverage of genetic testing and diagnostic procedures related to pregnancy and maternity care. The Newborns’ and Mothers’ Health Protection Act requires health plans to provide a minimum Hospital stay for the mother and newborn child of 48 hours after a normal, vaginal delivery and 96 hours after a C-section. The attending Physician, in consultation with the mother, may determine that a shorter length of stay is adequate. If your Hospital stay is shorter than the minimum stay, you can receive a follow-up visit with a Health Care Provider whose scope of practice includes postpartum and newborn care. This follow-up visit may occur at home or as an outpatient, as necessary. This visit will include parent education, assistance and training in breast or bottle feeding, and any necessary physical assessments for the mother and child. Prior authorization is not required for this follow-up visit.

Other Outpatient Mental Health and Substance Use Disorder Services. In addition to office visits, Benefits are available for other outpatient services for the diagnosis and treatment of Mental Health Conditions and Substance Use DisordersDisorder Conditions. You can receive these other outpatient services in a facility, office, home, or other non- non-institutional setting. Other Outpatient Mental Health and Substance Use Disorder Services include, but are not limited to: • Behavioral Health Treatment – professional services and treatment programs, including applied behavior analysis and evidence-based intervention programs, prescribed by a Physician or licensed psychologist and provided under a treatment plan approved by the MHSA to develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism; • Electroconvulsive therapy – the passing of a small electric current through the brain to induce a seizure, used in the treatment of severe depression; • Intensive Outpatient Program – outpatient care for mental health Mental Health Conditions or substance use disorders Substance Use Disorder Conditions when your condition requires structure, monitoring, and medical/psychological intervention at least three hours per day, three days per week; • Office-based opioid treatment – substance use disorder maintenance therapy, including methadone maintenance treatment; • Partial Hospitalization Program – an outpatient treatment program that may be in a free-standing or Hospital-based facility and provides services at least five hours per day, four days per week when you are admitted directly or transferred from acute inpatient care following stabilization; • Psychological Testing – testing to diagnose a mental health conditionMental Health Condition; and • Transcranial magnetic stimulation – a non-invasive method of delivering electrical stimulation to the brain for the treatment of severe depression. Benefits do not include: • Treatment for the purposes of providing respite, day care, or educational services, or to reimburse a parent for participation in the treatment. Benefits are available for inpatient facility and professional services for the treatment of Mental Health Conditions and Substance Use Disorders Disorder Conditions in: • A Hospital; or • A free-standing residential treatment center that provides 24-hour care when you do not require acute inpatient care. Medically Necessary inpatient substance use disorder detoxification is covered under the Hospital services Benefit. Benefits are available for services performed by a Physician, surgeon, or other Health Care Provider to diagnose or treat a medical condition. Benefits include: • Office visits for examination, diagnosis, counseling, education, consultation, and treatment; • Specialist office visits; • Urgent care center visits; • Second medical opinions; • Administration of injectable medications; • Outpatient services; • Inpatient services in a Hospital, Skilled Nursing Facility, residential treatment center, or emergency room; • Home visits; • Telehealth consultations, provided remotely via communication technologies, for examination, diagnosis, counseling, education, and treatment; and • Teladoc primary care consultations. See the Mental Health and Substance Use Disorder Benefits section for information on Mental Health and Substance Use Disorder office visits and Other Outpatient Mental Health and Substance Use Disorder services. Benefits are available for formulas and special food products if you are diagnosed with phenylketonuria (PKU). The items must be part of a diet prescribed and managed by a Physician or appropriately-licensed Health Care Provider. Benefits include: • Enteral formulas; and • Special food products for the dietary treatment of PKU. Benefits do not include: • Grocery store foods used by the general population; or • Food that is naturally low in protein, unless specially formulated to have less than one gram of protein per serving. Benefits are available for the diagnosis and treatment of conditions of the foot, ankle, and related structures. These services, including surgery, are generally provided by a licensed doctor of podiatric medicine. Benefits are available for maternity care services. Benefits include: • Prenatal care; • Postnatal care; • Involuntary complications of pregnancy; • Inpatient Hospital services including labor, delivery, and postpartum care; • Elective newborn circumcision within 18 months of birth; and • Pregnancy termination services. See the Diagnostic X-ray, imaging, pathology, and laboratory services and Preventive Health Services sections for information about coverage of genetic testing and diagnostic procedures related to pregnancy and maternity care. The Newborns’ and Mothers’ Health Protection Act requires health plans to provide a minimum Hospital stay for the mother and newborn child of 48 hours after a normal, vaginal delivery and 96 hours after a C-section. The attending Physician, in consultation with the mother, may determine that a shorter length of stay is adequate. If your Hospital stay is shorter than the minimum stay, you can receive a follow-up visit with a Health Care Provider whose scope of practice includes postpartum and newborn care. This follow-up visit may occur at home or as an outpatient, as necessary. This visit will include parent education, assistance and training in breast or bottle feeding, and any necessary physical assessments for the mother and child. Prior authorization is not required for this follow-up visit.

Other Outpatient Mental Health and Substance Use Disorder Services. In addition to office visits, Benefits are available for other outpatient services for the diagnosis and treatment of Mental Health and Substance Use Disorders. You can receive these other outpatient services in a facility, office, home, or other non- institutional setting. Other Outpatient Mental Health and Substance Use Disorder Services include, but are not limited to: • Behavioral Health Treatment – professional services and treatment programs, including applied behavior analysis and evidence-based intervention programs, prescribed by a Physician or licensed psychologist and provided under a treatment plan approved by the MHSA to develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism; • Electroconvulsive therapy – the passing of a small electric current through the brain to induce a seizure, used in the treatment of severe depression; • Intensive Outpatient Program – outpatient care for mental health or substance use disorders when your condition requires structure, monitoring, and medical/psychological intervention at least three hours per day, three days per week; • Office-based opioid treatment – substance use disorder maintenance therapy, including methadone maintenance treatment; • Partial Hospitalization Program – an outpatient treatment program that may be in a free-standing or Hospital-based facility and provides services at least five hours per day, four days per week when you are admitted directly or transferred from acute inpatient care following stabilization; • Psychological Testing – testing to diagnose a mental health condition; and • Transcranial magnetic stimulation – a non-invasive method of delivering electrical stimulation to the brain for the treatment of severe depression. Benefits do not include: • Treatment for the purposes of providing respite, day care, or educational services, or to reimburse a parent for participation in the treatment. Benefits are available for inpatient facility and professional services for the treatment of Mental Health and Substance Use Disorders in: • A Hospital; or • A free-standing residential treatment center that provides 24-hour care when you do not require acute inpatient care. Medically Necessary inpatient substance use disorder detoxification is covered under the Hospital services Benefit. Benefits are available for services performed by a Physician, surgeon, or other Health Care Provider to diagnose or treat a medical condition. Benefits include: • Office visits for examination, diagnosis, counseling, education, consultation, and treatment; • Specialist office visits; • Urgent care center visits; • Second medical opinions; • Administration of injectable medications; • Outpatient services; • Inpatient services in a Hospital, Skilled Nursing Facility, residential treatment center, or emergency room; • Home visits; • Telehealth consultations, provided remotely via communication technologies, for examination, diagnosis, counseling, education, and treatment; and • Teladoc primary care consultations. See the Mental Health and Substance Use Disorder Benefits section for information on Mental Health and Substance Use Disorder office visits and Other Outpatient Mental Health and Substance Use Disorder services. Benefits are available for formulas and special food products if you are diagnosed with phenylketonuria (PKU). The items must be part of a diet prescribed and managed by a Physician or appropriately-licensed Health Care Provider. Benefits include: • Enteral formulas; and • Special food products for the dietary treatment of PKU. Benefits do not include: • Grocery store foods used by the general population; or • Food that is naturally low in protein, unless specially formulated to have less than one gram of protein per serving. Benefits are available for the diagnosis and treatment of conditions of the foot, ankle, and related structures. These services, including surgery, are generally provided by a licensed doctor of podiatric medicine. Benefits are available for maternity care services. Benefits include: • Prenatal care; • Postnatal care; • Involuntary complications of pregnancy; • Inpatient Hospital services including labor, delivery, and postpartum care; • Elective newborn circumcision within 18 months of birth; and • Pregnancy termination services. See the Diagnostic X-ray, imaging, pathology, and laboratory services and Preventive Health Services sections for information about coverage of genetic testing and diagnostic procedures related to pregnancy and maternity care. The Newborns’ and Mothers’ Health Protection Act requires health plans to provide a minimum Hospital stay for the mother and newborn child of 48 hours after a normal, vaginal delivery and 96 hours after a C-section. The attending Physician, in consultation with the mother, may determine that a shorter length of stay is adequate. If your Hospital stay is shorter than the minimum stay, you can receive a follow-up visit with a Health Care Provider whose scope of practice includes postpartum and newborn care. This follow-up visit may occur at home or as an outpatient, as necessary. This visit will include parent education, assistance and training in breast or bottle feeding, and any necessary physical assessments for the mother and child. Prior authorization is not required for this follow-up visit.. You also have an option to receive up to a 90-day supply of prescription Drugs at a pharmacy in the Rx90 Retail network when you take maintenance Drugs for an ongoing condition. If your Physician or Health Care Provider writes a prescription for less than a 90-day supply, the pharmacy will only dispense the amount prescribed. You must pay the applicable retail pharmacy Drug Copayment or Coinsurance for each prescription Drug. Visit xxxxxxxxxxxx.xxx for additional information about how to get a 90-day supply of prescription Drugs from retail pharmacies. at a pharmacy in the Rx90 Retail network or

Other Outpatient Mental Health and Substance Use Disorder Services. In addition to office visits, Benefits are available for other outpatient services for the diagnosis and treatment of Mental Health and Substance Use Disorders. You can receive these other outpatient services in a facility, office, home, or other non- institutional setting. For Behavioral Health Crisis Services rendered by a Non-Participating Provider, you will pay the same Cost Share for Covered Services received from a Participating Provider. Prior authorization is not required for the Medically Necessary Treatment of a Mental Health or Substance Use Disorder provided by a 988 center, Mobile Crisis Team, or other Behavioral Health Crisis Services. Other Outpatient Mental Health and Substance Use Disorder Services include, but are not limited to: • Behavioral Health Treatment – professional services and treatment programs, including applied behavior analysis and evidence-based intervention programs, prescribed by a Physician or licensed psychologist and provided under a treatment plan approved by the MHSA to develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism; • Behavioral Health Crisis Services and other services provided by a 988 center, a Mobile Crisis Team, or other provider of Behavioral Health Crisis Services, regardless of whether the service is rendered by a Participating or Non- Participating Provider; • Electroconvulsive therapy – the passing of a small electric current through the brain to induce a seizure, used in the treatment of severe depression; • Intensive Outpatient Program – outpatient care for mental health or substance use disorders when your condition requires structure, monitoring, and medical/psychological intervention at least three hours per day, three days per week; • Office-based opioid treatment – substance use disorder maintenance therapy, including methadone maintenance treatment; • Partial Hospitalization Program – an outpatient treatment program that may be in a free-standing or Hospital-based facility and provides services at least five hours per day, four days per week when you are admitted directly or transferred from acute inpatient care following stabilization; • Psychological Testing – testing to diagnose a mental health condition; and • Transcranial magnetic stimulation – a non-invasive method of delivering electrical stimulation to the brain for the treatment of severe depression. Benefits do not include: • Treatment for the purposes of providing respite, day care, or educational services, or to reimburse a parent for participation in the treatment. Benefits are available for inpatient facility and professional services for the treatment of Mental Health and Substance Use Disorders in: • A Hospital; or • A free-standing residential treatment center that provides 24-hour care when you do not require acute inpatient care. Medically Necessary inpatient substance use disorder detoxification is covered under the Hospital services Benefit. Benefits are available for services performed by a Physician, surgeon, or other Health Care Provider to diagnose or treat a medical condition. Benefits include: • Office visits for examination, diagnosis, counseling, education, consultation, and treatment; • Specialist office visits; • Urgent care center visits; • Second medical opinions; • Administration of injectable medications; • Outpatient services; • Inpatient services in a Hospital, Skilled Nursing Facility, residential treatment center, or emergency room; • Home visits; • Telehealth consultations, provided remotely via communication technologies, for examination, diagnosis, counseling, education, and treatment; and • Teladoc primary care consultations. See the Mental Health and Substance Use Disorder Benefits section for information on Mental Health and Substance Use Disorder office visits and Other Outpatient Mental Health and Substance Use Disorder services. Benefits are available for formulas and special food products if you are diagnosed with phenylketonuria (PKU). The items must be part of a diet prescribed and managed by a Physician or appropriately-licensed Health Care Provider. Benefits include: • Enteral formulas; and • Special food products for the dietary treatment of PKU. Benefits do not include: • Grocery store foods used by the general population; or • Food that is naturally low in protein, unless specially formulated to have less than one gram of protein per serving. Benefits are available for the diagnosis and treatment of conditions of the foot, ankle, and related structures. These services, including surgery, are generally provided by a licensed doctor of podiatric medicine. Benefits are available for maternity care services. Benefits include: • Prenatal care; • Postnatal care; • Involuntary complications of pregnancy; • Inpatient Hospital services including labor, delivery, and postpartum care; • Elective newborn circumcision within 18 months of birth; and • Pregnancy termination services. See the Diagnostic X-ray, imaging, pathology, and laboratory services and Preventive Health Services sections for information about coverage of genetic testing and diagnostic procedures related to pregnancy and maternity care. The Newborns’ and Mothers’ Health Protection Act requires health plans to provide a minimum Hospital stay for the mother and newborn child of 48 hours after a normal, vaginal delivery and 96 hours after a C-section. The attending Physician, in consultation with the mother, may determine that a shorter length of stay is adequate. If your Hospital stay is shorter than the minimum stay, you can receive a follow-up visit with a Health Care Provider whose scope of practice includes postpartum and newborn care. This follow-up visit may occur at home or as an outpatient, as necessary. This visit will include parent education, assistance and training in breast or bottle feeding, and any necessary physical assessments for the mother and child. Prior authorization is not required for this follow-up visit.

Other Outpatient Mental Health and Substance Use Disorder Services. In addition to office visits, Benefits are available for other outpatient services for the diagnosis and treatment of Mental Health and Substance Use Disorders. You can receive these other outpatient services in a facility, office, home, or other non- institutional setting. Other Outpatient Mental Health and Substance Use Disorder Services include, but are not limited to: • Behavioral Health Treatment – professional services and treatment programs, including applied behavior analysis and evidence-based intervention programs, prescribed by a Physician or licensed psychologist and provided under a treatment plan approved by the MHSA to develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism; • Electroconvulsive therapy – the passing of a small electric current through the brain to induce a seizure, used in the treatment of severe depression; • Intensive Outpatient Program – outpatient care for mental health or substance use disorders when your condition requires structure, monitoring, and medical/psychological intervention at least three hours per day, three days per week; • Office-based opioid treatment – substance use disorder maintenance therapy, including methadone maintenance treatment; • Partial Hospitalization Program – an outpatient treatment program that may be in a free-standing or Hospital-based facility and provides services at least five hours per day, four days per week when you are admitted directly or transferred from acute inpatient care following stabilization; • Psychological Testing – testing to diagnose a mental health condition; and • Transcranial magnetic stimulation – a non-invasive method of delivering electrical stimulation to the brain for the treatment of severe depression. Benefits do not include: • Treatment for the purposes of providing respite, day care, or educational services, or to reimburse a parent for participation in the treatment. Benefits are available for inpatient facility and professional services for the treatment of Mental Health and Substance Use Disorders in: • A Hospital; or • A free-standing residential treatment center that provides 24-hour care when you do not require acute inpatient care. Medically Necessary inpatient substance use disorder detoxification is covered under the Hospital services Benefit. Benefits are available for services performed by a Physician, surgeon, or other Health Care Provider to diagnose or treat a medical condition. Benefits include: • Office visits for examination, diagnosis, counseling, education, consultation, and treatment; • Specialist office visits; • Urgent care center visits; • Second medical opinions; • Administration of injectable medications; • Outpatient services; • Inpatient services in a Hospital, Skilled Nursing Facility, residential treatment center, or emergency room; • Home visits; • Telehealth consultations, provided remotely via communication technologies, for examination, diagnosis, counseling, education, and treatment; and • Teladoc primary care consultations. See the Mental Health and Substance Use Disorder Benefits section for information on Mental Health and Substance Use Disorder office visits and Other Outpatient Mental Health and Substance Use Disorder services. Benefits are available for formulas and special food products if you are diagnosed with phenylketonuria (PKU). The items must be part of a diet prescribed and managed by a Physician or appropriately-licensed Health Care Provider. Benefits include: • Enteral formulas; and • Special food products for the dietary treatment of PKU. Benefits do not include: • Grocery store foods used by the general population; or • Food that is naturally low in protein, unless specially formulated to have less than one gram of protein per serving. Benefits are available for the diagnosis and treatment of conditions of the foot, ankle, and related structures. These services, including surgery, are generally provided by a licensed doctor of podiatric medicine. Benefits are available for maternity care services. Benefits include: • Prenatal care; • Postnatal care; • Involuntary complications of pregnancy; • Inpatient Hospital services including labor, delivery, and postpartum care; • Elective newborn circumcision within 18 months of birth; and • Pregnancy termination services. See the Diagnostic X-ray, imaging, pathology, and laboratory services and Preventive Health Services sections for information about coverage of genetic testing and diagnostic procedures related to pregnancy and maternity care. The Newborns’ and Mothers’ Health Protection Act requires health plans to provide a minimum Hospital stay for the mother and newborn child of 48 hours after a normal, vaginal delivery and 96 hours after a C-section. The attending Physician, in consultation with the mother, may determine that a shorter length of stay is adequate. If your Hospital stay is shorter than the minimum stay, you can receive a follow-up visit with a Health Care Provider whose scope of practice includes postpartum and newborn care. This follow-up visit may occur at home or as an outpatient, as necessary. This visit will include parent education, assistance and training in breast or bottle feeding, and any necessary physical assessments for the mother and child. Prior authorization is not required for this follow-up visit.

Other Outpatient Mental Health and Substance Use Disorder Services. In addition to office visits, Benefits are available for other outpatient services for the diagnosis and treatment of Mental Health and Substance Use Disorders. You can receive these other outpatient services in a facility, office, home, or other non- institutional setting. For Behavioral Health Crisis Services rendered by a Non-Participating Provider, you will pay the same Cost Share for Covered Services received from a Participating Provider. Prior authorization is not required for the Medically Necessary Treatment of a Mental Health or Substance Use Disorder provided by a 988 center, Mobile Crisis Team, or other Behavioral Health Crisis Services. Other Outpatient Mental Health and Substance Use Disorder Services include, but are not limited to: • Behavioral Health Treatment – professional services and treatment programs, including applied behavior analysis and evidence-based intervention programs, prescribed by a Physician or licensed psychologist and provided under a treatment plan approved by the MHSA to develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism; • Behavioral Health Crisis Services and other services provided by a 988 center, a Mobile Crisis Team, or other provider of Behavioral Health Crisis Services, regardless of whether the service is rendered by a Participating or Non- Participating Provider; • Electroconvulsive therapy – the passing of a small electric current through the brain to induce a seizure, used in the treatment of severe depression; • Intensive Outpatient Program – outpatient care for mental health or substance use disorders when your condition requires structure, monitoring, and medical/psychological intervention at least three hours per day, three days per week; • Office-based opioid treatment – substance use disorder maintenance therapy, including methadone maintenance treatment; • Partial Hospitalization Program – an outpatient treatment program that may be in a free-standing or Hospital-based facility and provides services at least five hours per day, four days per week when you are admitted directly or transferred from acute inpatient care following stabilization; • Psychological Testing – testing to diagnose a mental health condition; and • Transcranial magnetic stimulation – a non-invasive method of delivering electrical stimulation to the brain for the treatment of severe depression. Benefits do not include: • Treatment for the purposes of providing respite, day care, or educational services, or to reimburse a parent for participation in the treatment. Benefits are available for inpatient facility and professional services for the treatment of Mental Health and Substance Use Disorders in: • A Hospital; or • A free-standing residential treatment center that provides 24-hour care when you do not require acute inpatient care. Medically Necessary inpatient substance use disorder detoxification is covered under the Hospital services Benefit. Benefits are available for services performed by a Physician, surgeon, or other Health Care Provider to diagnose or treat a medical condition. Benefits include: • Office visits for examination, diagnosis, counseling, education, consultation, and treatment; • Specialist office visits; • Urgent care center visits; • Second medical opinions; • Administration of injectable medications; • Administration of radiopharmaceutical medications; • Outpatient services; • Inpatient services in a Hospital, Skilled Nursing Facility, residential treatment center, or emergency room; • Home visits; • Telehealth consultations, provided remotely via communication technologies, for examination, diagnosis, counseling, education, and treatment. Coverage for these services will be on the same basis and to the same extent as a service conducted in person; and • Teladoc primary care general medical consultations. See the Mental Health and Substance Use Disorder Benefits section for information on Mental Health and Substance Use Disorder office visits and Other Outpatient Mental Health and Substance Use Disorder services. Benefits are available for formulas and special food products if you are diagnosed with phenylketonuria (PKU). The items must be part of a diet prescribed and managed by a Physician or appropriately-licensed Health Care Provider. Benefits include: • Enteral formulas; and • Special food products for the dietary treatment of PKU. Benefits do not include: • Grocery store foods used by the general population; or • Food that is naturally low in protein, unless specially formulated to have less than one gram of protein per serving. Benefits are available for the diagnosis and treatment of conditions of the foot, ankle, and related structures. These services, including surgery, are generally provided by a licensed doctor of podiatric medicine. Benefits are available for maternity care services. Benefits include: • Prenatal care; • Postnatal care; • Involuntary complications of pregnancy; • Inpatient Hospital services including labor, delivery, and postpartum care; • Elective newborn circumcision within 18 months of birth; and • Pregnancy termination services. See the Diagnostic X-ray, imaging, pathology, and laboratory services and Preventive Health Services sections for information about coverage of genetic testing and diagnostic procedures related to pregnancy and maternity care. The Newborns’ and Mothers’ Health Protection Act requires health plans to provide a minimum Hospital stay for the mother and newborn child of 48 hours after a normal, vaginal delivery and 96 hours after a C-section. The attending Physician, in consultation with the mother, may determine that a shorter length of stay is adequate. If your Hospital stay is shorter than the minimum stay, you can receive a follow-up visit with a Health Care Provider whose scope of practice includes postpartum and newborn care. This follow-up visit may occur at home or as an outpatient, as necessary. This visit will include parent education, assistance and training in breast or bottle feeding, and any necessary physical assessments for the mother and child. Prior authorization is not required for this follow-up visit.

Other Outpatient Mental Health and Substance Use Disorder Services. In addition to office visits, Benefits are available for other outpatient services for the diagnosis and treatment of Mental Health Conditions and Substance Use DisordersDisorder Conditions. You can receive these other outpatient services in a facility, office, home, or other non- non-institutional setting. Other Outpatient Mental Health and Substance Use Disorder Services include, but are not limited to: • Behavioral Health Treatment – professional services and treatment programs, including applied behavior analysis and evidence-based intervention programs, prescribed by a Physician or licensed psychologist and provided under a treatment plan approved by the MHSA to develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism; • Electroconvulsive therapy – the passing of a small electric current through the brain to induce a seizure, used in the treatment of severe depression; • Intensive Outpatient Program – outpatient care for mental health Mental Health Conditions or substance use disorders Substance Use Disorder Conditions when your condition requires structure, monitoring, and medical/psychological intervention at least three hours per day, three days per week; • Office-based opioid treatment – substance use disorder maintenance therapy, including methadone maintenance treatment; • Partial Hospitalization Program – an outpatient treatment program that may be in a free-standing or Hospital-based facility and provides services at least five hours per day, four days per week when you are admitted directly or transferred from acute inpatient care following stabilization; • Psychological Testing – testing to diagnose a mental health conditionMental Health Condition; and • Transcranial magnetic stimulation – a non-invasive method of delivering electrical stimulation to the brain for the treatment of severe depression. Benefits do not include: • Treatment for the purposes of providing respite, day care, or educational services, or to reimburse a parent for participation in the treatment. Benefits are available for inpatient facility and professional services for the treatment of Mental Health Conditions and Substance Use Disorders Disorder Conditions in: • A Hospital; or • A free-standing residential treatment center that provides 24-hour care when you do not require acute inpatient care. Medically Necessary inpatient substance use disorder detoxification is covered under the Hospital services Benefit. Benefits are available for services performed by a Physician, surgeon, or other Health Care Provider to diagnose or treat a medical condition. Benefits include: • Office visits for examination, diagnosis, counseling, education, consultation, and treatment; • Specialist office visits; • Urgent care center visits; • Second medical opinions; • Administration of injectable medications; • Outpatient services; • Inpatient services in a Hospital, Skilled Nursing Facility, residential treatment center, or emergency room; • Home visits; • Telehealth consultations, provided remotely via communication technologies, for examination, diagnosis, counseling, education, and treatment; and • Teladoc primary care consultations. See the Mental Health and Substance Use Disorder Benefits section for information on Mental Health and Substance Use Disorder office visits and Other Outpatient Mental Health and Substance Use Disorder services. Benefits are available for formulas and special food products if you are diagnosed with phenylketonuria (PKU). The items must be part of a diet prescribed and managed by a Physician or appropriately-licensed Health Care Provider. Benefits include: • Enteral formulas; and • Special food products for the dietary treatment of PKU. Benefits do not include: • Grocery store foods used by the general population; or • Food that is naturally low in protein, unless specially formulated to have less than one gram of protein per serving. Benefits are available for the diagnosis and treatment of conditions of the foot, ankle, and related structures. These services, including surgery, are generally provided by a licensed doctor of podiatric medicine. Benefits are available for maternity care services. Benefits include: • Prenatal care; • Postnatal care; • Involuntary complications of pregnancy; • Inpatient Hospital services including labor, delivery, and postpartum care; • Elective newborn circumcision within 18 months of birth; and • Pregnancy termination services. See the Diagnostic X-ray, imaging, pathology, and laboratory services and Preventive Health Services sections for information about coverage of genetic testing and diagnostic procedures related to pregnancy and maternity care. The Newborns’ and Mothers’ Health Protection Act requires health plans to provide a minimum Hospital stay for the mother and newborn child of 48 hours after a normal, vaginal delivery and 96 hours after a C-section. The attending Physician, in consultation with the mother, may determine that a shorter length of stay is adequate. If your Hospital stay is shorter than the minimum stay, you can receive a follow-up visit with a Health Care Provider whose scope of practice includes postpartum and newborn care. This follow-up visit may occur at home or as an outpatient, as necessary. This visit will include parent education, assistance and training in breast or bottle feeding, and any necessary physical assessments for the mother and child. Prior authorization is not required for this follow-up visit.