Common use of Services M† ental Health and Substance Use Disorder Clause in Contracts

Services M† ental Health and Substance Use Disorder. Inpatient- Unlimited days at a generhaol spitalor a specialtyhospitalincluding detoxification or residential/rehabilitation ppelran year. Preauthorizationmay be required for services received from anon-network xxxxxx.xx 0%- Afterdeductible 20%- Afterdeductible Outpatientor intermediate care service-sSee Covered Healthcare Services: Behavioral Health Section for det about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorizationmaybe required for services received from anon-network xxxxxx.xx 0%- Afterdeductible 20%- Afterdeductible Office visit-sSee Office Visits section below for Behavi Health services provided byPaCP or specialist. Psychological testing 0%- Afterdeductible 20%- Afterdeductible Medicatio-nassisted treatment- when rendered by a mental health or substance use disordperovide.r $30 20%- Afterdeductible Methadone maintenance treatme-not ne copaymentper seven day period of treatment. $30 20%- Afterdeductible Cardiac Rehabilitation Outpatient- Benefitis limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 0%- Afterdeductible 20%- Afterdeductible In aphysician’soffice- limited to 20 visits ppelran year. $50 20%- Afterdeductible

Services M† ental Health and Substance Use Disorder. Inpatient- Unlimited days at a generhaol spitalor a specialtyhospitalincluding detoxification or residential/rehabilitation ppelran year. Preauthorizationmay be required for services received from anon-network xxxxxx.xx 0%- 20%- Afterdeductible 20%- 40%- Afterdeductible Outpatientor intermediate care service-sSee Covered Healthcare Services: Behavioral Health Section for det about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorizationmaybe required for services received from anon-network xxxxxx.xx 0%- 20%- Afterdeductible 20%- 40%- Afterdeductible Office visit-sSee Office Visits section below for Behavi Health services provided byPaCP or specialist. Psychological testing 0%- Afterdeductible 20%- 0% 40%- Afterdeductible Medicatio-nassisted treatment- when rendered by a mental health or substance use disordperovide.r $30 20%- 25 40%- Afterdeductible Methadone maintenance treatme-not ne copaymentper seven day period of treatment. $30 20%- 25 40%- Afterdeductible Cardiac Rehabilitation Outpatient- Benefitis limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 0%- 20%- Afterdeductible 20%- 40%- Afterdeductible In aphysician’soffice- limited to 20 12 visits ppelran year. $50 20%- 40 40%- Afterdeductible

Services M† ental Health and Substance Use Disorder. Inpatient- Unlimited days at a generhaol spitalor a specialtyhospitalincluding detoxification or residential/rehabilitation ppelran year. Preauthorizationmay be required for services received from anon-network xxxxxx.xx 0%- Afterdeductible 0% 20%- Afterdeductible Outpatientor intermediate care service-sSee Covered Healthcare Services: Behavioral Health Section for det about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorizationmaybe required for services received from anon-network xxxxxx.xx 0%- Afterdeductible 0% 20%- Afterdeductible Office visit-sSee Office Visits section below for Behavi Health services provided byPaCP or specialist. Psychological testing 0%- Afterdeductible 0% 20%- Afterdeductible Medicatio-nassisted treatment- when rendered by a mental health or substance use disordperovide.r $30 15 20%- Afterdeductible Methadone maintenance treatme-not ne copaymentper seven day period of treatment. $30 15 20%- Afterdeductible Cardiac Rehabilitation Outpatient- Benefitis limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 0%- Afterdeductible 0% 20%- Afterdeductible In aphysician’soffice- limited to 20 12 visits ppelran year. $50 15 20%- Afterdeductible

Services M† ental Health and Substance Use Disorder. Inpatient- Unlimited days at a generhaol spitalor a specialtyhospitalincluding detoxification or residential/rehabilitation ppelran year. Preauthorizationmay be required for services received from anon-network xxxxxx.xx 0%- Afterdeductible 20%- 40%- Afterdeductible Outpatientor intermediate care service-sSee Covered Healthcare Services: Behavioral Health Section for det about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorizationmaybe required for services received from anon-network xxxxxx.xx 0%- Afterdeductible 20%- 40%- Afterdeductible Office visit-sSee Office Visits section below for Behavi Health services provided byPaCP or specialist. Psychological testing 0%- Afterdeductible 20%- 40%- Afterdeductible Medicatio-nassisted treatment- when rendered by a mental health or substance use disordperovide.r $30 20%- 0%- Afterdeductible 40%- Afterdeductible Methadone maintenance treatme-not ne copaymentper seven day period of treatment. $30 20%- 0%- Afterdeductible 40%- Afterdeductible Cardiac Rehabilitation Outpatient- Benefitis limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 0%- Afterdeductible 20%- 40%- Afterdeductible In aphysician’soffice- limited to 20 12 visits ppelran year. $50 20%- 0%- Afterdeductible 40%- Afterdeductible