All diagnostic and treatment services for which prior approval is optained.

Note: Preferred benefits are payable only when we determine that the care is clinically appropriate to treat your condition and only when you receive the care from a Preferred provider.

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

Professional services, including individual or group therapy by providers such as psychiatrists, psychologists, clinical social workers or psychiatric nurses

• Office and home visits
• In a hospital outpatient department (except for emergency rooms)
• Psychotherapy for smoking cessation

Note: Additional types of licensed providers may be available to you for mental health and substance abuse services. Consult your PPO directory or contact your Local Plan at the Mental Health/Substance Abuse phone number on the back of your ID card.

Preferred primary care provider or other healthcare professional: $25 copayment per visit

Preferred specialist: $35 copayment per visit

Note: You pay a $75 copayment for outpatient services billed for by a facility.

Note: You pay 30% of the Plan allowance for drugs and supplies.

• Pharmacotherapy (medication management)
• Psychological testing

Preferred primary care provider or other health care professional: $25 copayment per visit

Preferred specialist: $35 copayment per visit

Note: You pay 30% of the Plan allowance for drugs and supplies.

• Inpatient professional visits
• Professional charges for facility-based intensive outpatient treatment

Nothing

• Professional charges for intensive outpatient treatment in a provider's office or other professional setting

Preferred: $30 copayment per visit

• Professional charges for outpatient diagnostic tests

Nothing

Inpatient services provided and billed by a hospital or other covered facility

• Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets and other hospital services
• Diagnostic tests

Note: You must get precertification of inpatient hospital stays; failure to do so will result in a $500 penalty.

$150 per day copayment up to $750 per admission

Outpatient services provided and billed by a hospital or other covered facility

• Diagnostic tests
• Services in the following approved treatment programs:
  • partial hospitalization
  • facility-based intensive outpatient treatment

$75 copayment per day per facility

Note: For outpatient diagnostic or psychological tests billed for by a Preferred, Member, or Non-member facility, you pay nothing.

Note: You pay 30% of the Plan allowance for drugs.

Not covered:

• Services we have not approved
• Educational or training services
• Psychoanalysis or psychotherapy credited toward earning a degree or furtherance of education or training regardless of diagnosis or symptoms that may be present
• Services performed or billed by residential therapeutic camps (e.g., wilderness camps, Outward Bound, etc.)
• Light boxes

All charges