|
REGULAR
PLAN PPO |
LOW
OPTION PLAN
(For COBRA Participants and Extended Coverage Participants Only) |
| MENTAL
HEALTH AND SUBSTANCE ABUSE (MH&SA) 1 |
PBH
PROVIDER 2, 3 |
NON-PBH
PROVIDER 2 |
OUT
OF AREA 2 |
PBH
PROVIDER 2, 3 |
NON-PBH
PROVIDER 2 |
| Outpatient |
100%
after $15 copay, up to 45 non-SMI (4) visits and 70 SMI (4) visits
(combined)/
calendar year |
70%,
up to 20 visits/
calendar year |
70%,
up to 20 visits/
calendar year |
100%
after $15 copay, up to 45 visits for non-SMI (4) visits and 70 SMI
(4) visits (combined)/
calendar year |
70%,
up to 20 visits/
calendar year |
|
Inpatient
|
100%
after $200 copay/
admission, up to 45 days/
calendar year |
70%
after $200 copay/
admission, up to a lifetime maximum of 14 days |
70%
after $200 copay/
admission, up to a lifetime maximum of 14 days |
100%
after $200 copay/
admission, up to 45 days/
calendar year |
70%
after $200 copay /
admission, up to a lifetime maximum of 14 days |
1. Mental
health and substance abuse benefits are combined.
2. Visits to both PBH and non-PBH providers count toward each other's
annual visit limit.
3. Precertification required.
4 SMI: serious mental illness. Diagnoses include schizophrenia, schizoaffective
disorder, bipolar disorder, major depressive disorder, manic depressive
disorder, obsessive-compulsive disorder, pervasive developmental disorder
(autism), anorexia nervosa, bulmia nervosa and severe emotional disturbances
of children.
|
