Common use of Behavioral Health Services – Mental Health and Substance Use Disorder Clause in Contracts

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible 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. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% 20% - After deductible Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 20% - After deductible Methadone maintenance treatment - one copayment per seven day period of treatment. $30 20% - After deductible Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 0% - After deductible 20% - After deductible

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. *Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible 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. *Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing testing 0% 20% - After deductible Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 20% - After deductible Methadone maintenance treatment - one copayment per seven day period of treatment. $30 20% - After deductible Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 0% - After deductible 20% - After deductible

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible 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. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing testing 0% - After deductible 20% - After deductible Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 20 20% - After deductible Methadone maintenance treatment - one copayment per seven day period of treatment. $30 20 20% - After deductible Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 0% - After deductible 20% - After deductible

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 020% - After deductible 2040% - After deductible 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. Preauthorization may be required for services received from a non-network provider. 020% - After deductible 2040% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% 2040% - After deductible Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 2040 40% - After deductible Methadone maintenance treatment - one copayment per seven day period of treatment. $30 2040 40% - After deductible Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 020% - After deductible 2040% - After deductible

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 2040% - After deductible 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. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 2040% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% 2040% - After deductible Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 2020 40% - After deductible Methadone maintenance treatment - one copayment per seven day period of treatment. $30 2020 40% - After deductible Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 0% - After deductible 2040% - After deductible

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 020% - After deductible 2040% - After deductible 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. Preauthorization may be required for services received from a non-network provider. 020% - After deductible 2040% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% 2040% - After deductible Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 2015 40% - After deductible Methadone maintenance treatment - one copayment per seven day period of treatment. $30 2015 40% - After deductible Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 020% - After deductible 2040% - After deductible

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible 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. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 20% - After deductible Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 20% - After deductible Methadone maintenance treatment - one copayment per seven seven-day period of treatment. $30 20% - After deductible Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 0% - After deductible 20% - After deductible

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. *Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible 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. *Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing testing 0% 20% - After deductible Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 25 20% plus $25 - After deductible Afterdeductible Methadone maintenance treatment - one copayment per seven day period of treatment. $30 25 20% plus $25 - After deductible Afterdeductible Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 020% - After deductible 20% - After deductible

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. *Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible 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. *Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing testing 0% 20% - After deductible Medication-assisted treatment - when rendered by renderedby a mental health or substance use disorder provider. $30 20% - After deductible Methadone maintenance treatment - one copayment per copaymentper seven day period of treatment. $30 20% - After deductible Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 0% - After deductible 20% - After deductible

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible 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. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing testing 0% 20% - After deductible Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 25 20% - After deductible Methadone maintenance treatment - one copayment per seven day period of treatment. $30 25 20% - After deductible Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 0% - After deductible 20% - After deductible

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% $300 per admission - After deductible 20% - After deductible Afterdeductible 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. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% 20% - After deductible Not Covered Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 20% 35 - After deductible Not Covered Methadone maintenance treatment - one copayment per seven day period of treatment. $30 20% 35 - 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 20% - After deductibleNot Covered

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. *Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible 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. *Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing testing 0% 20% - After deductible Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 25 20% plus $25 - After deductible Methadone maintenance treatment - one copayment per seven day period of treatment. $30 25 20% plus $25 - After deductible Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 020% - After deductible 20% - After deductible

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible 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. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% 20% - After deductible Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 15 20% - After deductible Methadone maintenance treatment - one copayment per seven day period of treatment. $30 15 20% - After deductible Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 0% - After deductible 20% - After deductible

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible 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. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% 20% - After deductible Medication-assisted treatment - when rendered by a mental health or substance use disorder provider. $30 40 20% - After deductible Methadone maintenance treatment - one copayment per seven day period of treatment. $30 40 20% - After deductible Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 0% - After deductible 20% - After deductible

Behavioral Health Services – Mental Health and Substance Use Disorder. Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible Outpatient or intermediate care servicescareservices* - 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. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 20% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% 20% - After deductible Medication-assisted treatment - when rendered by whenrenderedby a mental health or substance use disorder provider. $30 20% - After deductible Methadone maintenance treatment - one copayment per seven day period of treatment. $30 20% - After deductible Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episodecoveredepisode. 0% - After deductible 20% - After deductible Chiropractic Services In a physician's office - limited to 12 visits per plan year. $45 20% - After deductible