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 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. Notification of services may be required. 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 Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. 0% - After deductible Not Covered Methadone maintenance treatment. 0% - After deductible 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 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 Not Covered Outpatient or intermediate care services 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 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 Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. 0% - After deductible Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 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 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. 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. Notification of services may be required. 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 Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. 0% - After deductible $35 Not Covered Methadone maintenance treatment. 0% - After deductible $0 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 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. 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. Notification of services may be required. 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 Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. 0% - After deductible $45 Not Covered Methadone maintenance treatment. 0% - After deductible $0 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 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. 020% - After deductible Not Covered Outpatient or intermediate care services 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. 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 Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. 0% - After deductible $30 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible $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 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. 010% - After deductible Not Covered Outpatient or intermediate care services careservices* - 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. 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 Medication-assisted treatment - when rendered by whenrenderedby a mental health or substance use disorder provider. 0% - After deductible $20 Not Covered Methadone maintenance treatment - one copayment per seven day period of treatment. 0% - After deductible $20 Not Covered Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episodecoveredepisode. 010% - After deductible Not Covered

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 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. Notification of services may be required. 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 Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. 0% $15 - After deductible Not Covered Methadone maintenance treatment. 0% $0 - After deductible 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 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. 010% - After deductible Not Covered Outpatient or intermediate care services 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. 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 Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. 0% - After deductible $45 Not Covered Methadone maintenance treatment - one copayment per seven day period of treatment. 0% - After deductible $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 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 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. Notification of services may be required. 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 Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. 0% - After deductible $25 Not Covered Methadone maintenance treatment. 0% - After deductible $0 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 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 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. Notification of services may be required. 0% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing testing 0% - After deductible Not Covered Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. 0% - After deductible Not Covered Methadone maintenance treatment. 0% - After deductible 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 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 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. Notification of services may be required. 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 Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. 0% - After deductible $20 Not Covered Methadone maintenance treatment. 0% - After deductible $0 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 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 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. Notification of services Preauthorization may be requiredrequired for services received from a non-network provider. 0% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing testing 0% - After deductible Not Covered Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. 0% - After deductible Not Covered Methadone maintenance treatment - one copayment per seven day period of treatment. 0% - After deductible 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 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. 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. Notification of services may be required. 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 Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. 0% - After deductible $30 Not Covered Methadone maintenance treatment. 0% - After deductible $0 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 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 Not Covered Outpatient or intermediate care services 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 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 Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. 0% - After deductible $30 Not Covered Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible $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 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. 020% - After deductible Not Covered Outpatient or intermediate care services 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. 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 Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. 0% - After deductible $30 Not Covered Methadone maintenance treatment - one copayment per seven day period of treatment. 0% - After deductible $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 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 Not Covered Outpatient or intermediate care services careservices - 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 Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing testing 0% - After deductible Not Covered Medication-assisted treatment - when rendered by whenrenderedby a mental health or substance use disorder provider. 0% - After deductible $20 Not Covered Methadone maintenance treatment - one copayment per seven day period of treatment. 0% - After deductible $20 Not Covered Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episodecoveredepisode. 0% - After deductible Not Covered

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. 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. Notification of services may be required. 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 Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. 010% - After deductible Not Covered Methadone maintenance treatment. 0% - After deductible 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 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. 010% - After deductible Not Covered Outpatient or intermediate care services 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. 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 Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. 0% - After deductible $30 Not Covered Methadone maintenance treatment - one copayment per seven day period of treatment. 0% - After deductible $30 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 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 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. Notification of services may be required. 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 Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. 0% - After deductible $30 Not Covered Methadone maintenance treatment. 0% - After deductible $0 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 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 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. Notification of services may be required. 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 Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. 0% - After deductible $30 Not Covered Methadone maintenance treatment. 0% - After deductible $0 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 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% $300 per admission - After deductible Not Covered Outpatient or intermediate care services careservices* - 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 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 Medication-assisted treatment - when rendered by whenrenderedby a mental health or substance use disorder provider. 0% $35 - After deductible Not Covered Methadone maintenance treatment - one copayment per seven day period of treatment. 0% $35 - After deductible Not Covered Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episodecoveredepisode. 0% - After deductible Not Covered

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 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. Notification of services Preauthorization may be requiredrequired for services received from a non-network provider. 0% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing testing 0% - After deductible Not Covered Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. 0% - After deductible $20 Not Covered Methadone maintenance treatment - one copayment per seven day period of treatment. 0% - After deductible $20 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