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. 10% - After deductible Not Covered Outpatient or intermediate 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. Preauthorization may be required for services received from a non-network provider. 10% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 10% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $25 Not Covered Methadone maintenance treatment - one copayment per seven day period of treatment. $25 Not Covered Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 10% - After deductible Not 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. 100% - After deductible Not Covered Outpatient or intermediate careservicescare 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. 100% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 100% - After deductible Not Covered Medication-assisted treatment - whenrenderedby when rendered by a mental health or substance use disorder provider. $25 Not Covered Methadone maintenance treatment - one copayment per seven day period of treatment. $25 Not Covered Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisodecovered episode. 100% - After deductible Not 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. 100% - After deductible Not Covered Outpatient or intermediate careservices* 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. Preauthorization may be required for services received from a non-network provider. 100% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 10testing 0% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $25 0% - After deductible Not Covered Methadone maintenance treatment - one copayment per seven day period of treatment. $25 0% - After deductible Not Covered Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 100% - After deductible Not 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. 10% - After deductible Not Covered Outpatient or intermediate 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. Preauthorization may be required for services received from a non-network provider. 10% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 10% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $25 30 Not Covered Methadone maintenance treatment - one copayment per seven day period of treatment. $25 30 Not Covered Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 10% - After deductible Not 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. 100% - After deductible Not Covered Outpatient or intermediate careservicescare 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. 100% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 100% - After deductible Not Covered Medication-assisted treatment - whenrenderedby when rendered by a mental health or substance use disorder provider. $25 Not Covered Methadone maintenance treatment - one copayment per seven seven-day period of treatment. $25 Not Covered Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisodecovered episode. 100% - After deductible Not 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. 100% - After deductible Not Covered Outpatient or intermediate 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. Preauthorization may be required for services received from a non-network provider. 100% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 100% - After deductible Not Covered Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. $25 20 Not Covered Methadone maintenance treatment - one copayment per seven day period of treatment. $25 20 Not Covered Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 100% - After deductible Not 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. 10% - After deductible Not Covered Outpatient or intermediate careservicescare 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. 10% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 10% - After deductible Not Covered Medication-assisted treatment - whenrenderedby when rendered by a mental health or substance use disorder provider. $25 35 Not Covered Methadone maintenance treatment - one copayment per seven day period of treatment. $25 35 Not Covered Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisodecovered episode. 10% - After deductible Not 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. 100% - After deductible Not Covered Outpatient or intermediate careservicescare 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. 100% - After deductible Not Covered Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 100% - After deductible Not Covered Medication-assisted treatment - whenrenderedby when rendered by a mental health or substance use disorder provider. $25 20 Not Covered Methadone maintenance treatment - one copayment per seven day period of treatment. $25 20 Not Covered Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisodecovered episode. 100% - After deductible Not Covered