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Mental Health Care and Substance Related and Addictive Disorder Services

Mental Health Care and Substance-Related and Addictive Disorders Services include those received on an
inpatient or outpatient basis in a Hospital, an Alternate Facility or in a provider's office. All services must be
provided by or under the direction of a properly qualified behavioral health provider. All services must be provided
by or under the direction of a properly qualified behavioral health provider.

Benefits include the following levels of care:
· Inpatient treatment.

· Residential Treatment Facility.
· Partial Hospitalization/Day Treatment.

· Intensive Outpatient Treatment.
Benefits will be provided for the following Covered Health Care Services to treat a Mental Health Condition:

· Diagnostic evaluations, assessment and treatment planning.
· Treatment and/or procedures.

· Medication management and other associated treatments.
· Individual, family, and group therapy and provider-based case management services.

· Crisis intervention.
· Mental Health Care Services for Autism Spectrum Disorder (including Intensive Behavioral Therapies
such as Applied Behavioral Analysis (ABA) that are the following:
· Focused on the treatment of core deficits of Autism Spectrum Disorder.

· Provided by a Board Certified Behavior Analyst (BCBA) or other qualified provider under the
appropriate supervision.
· Focused on treating maladaptive/stereotypic behaviors that are posing danger to self, others and
property, and impairment in daily functioning.
This section describes only the behavioral component of treatment for Autism Spectrum Disorder. Medical
treatment of Autism Spectrum Disorder is a Covered Health Service for which Benefits are available under the
applicable medical Covered Health Care Services categories in this Summary Plan Description.
The Mental Health/Substance Use Disorder Designee provides administrative services for all levels of care.

We encourage you to contact the Mental Health/Substance Use Disorder Designee for referrals to providers and
coordination of care.
Pharmaceutical Products

Pharmaceutical Products for Covered Health Care Services administered on an outpatient basis in a Hospital,
Alternate Facility, Physician's office, or in your home.
Benefits are provided for Pharmaceutical Products which, due to their traits (as determined by us), are
administered or directly supervised by a qualified provider or licensed/certified health professional. Depending on
where the Pharmaceutical Product is administered, Benefits will be provided for administration of the
Pharmaceutical Product under the corresponding Benefit category in the Summary Plan Description. Benefits for
medication normally available by a prescription order or refill are provided as described under your Outpatient
Prescription Drug Benefit.

Physician Fees for Surgical Services

Covered Health Care Services include Physician fees for surgical procedures received on an outpatient or
inpatient basis in a Physician’s Office, Hospital, Skilled Nursing Facility, Inpatient Rehabilitation Facility or
Alternate Facility.

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PPO - 2017