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. 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. 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 Methadone maintenance treatment $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. 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. 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 Methadone maintenance treatment $40 50 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. 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. 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 Methadone maintenance treatment $40 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. 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. 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% 20- After deductible 40% - After deductible Methadone maintenance treatment $40 200% - After deductible 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. 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. 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 Methadone maintenance treatment $40 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. 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. 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 Methadone maintenance treatment $40 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. 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. 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 Methadone maintenance treatment $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