Situation

CHOICE PLUS

NETWORK

CHOICE PLUS

NON-NETWORK

Vendor

United Behavioral Health

Employer Division

Call 1-877-348-9411

United Behavioral Health

Employer Division

Call 1-877-348-9411

Mental Health Inpatient or Intermediate

The Plan covers Mental Health Treatment which is:

●  Pre-authorized by the

Mental Health/ Substance Abuse Administrator, who is responsible for coordinating all of your care; and

●  Received on an inpatient or intermediate care basis in a Hospital or an Alternate Facility which provides Mental Health Treatment.

If there are multiple diagnoses, the Plan will only pay for treatment of the diagnoses which are identified in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (APA). Benefits include detoxification from abusive chemicals or substances when necessary to protect your health. APA's website is www.apa.org.

If the MH/SA Administrator determines that an Inpatient Stay is required, it is covered on a semi-private room (a room with two or more beds) basis. At the sole discretion of the MH/SA Administrator, two sessions of intermediate care (such as partial hospitalization) may be provided in lieu of one inpatient day.

90% of eligible expenses.

Any combination of Network and Non-Network Benefits for Mental Health Services and/or Substance Abuse Services is limited to 60 days per Calendar Year.

Authorization Required

Please remember that you must call the Mental Health/Substance Abuse Administrator and get authorization to receive these Benefits in advance of any treatment. Please call the mental health services phone number that appears on your ID card.

Without authorization, you will be responsible for paying all charges and no Benefits will be paid.

80% of eligible expenses after satisfying $300 deductible.

Any combination of Network and Non-Network Benefits for Mental Health Services and/or Substance Abuse Services is limited to 60 days per Calendar Year.

Authorization Required

Please remember that you must call the Mental Health/Substance Abuse Administrator and get authorization to receive these Benefits in advance of any treatment. Please call the mental health services phone number that appears on your ID card.

Without authorization, you will be responsible for paying all charges and no Benefits will be paid.

Mental Health Services Outpatient

The Plan covers mental health treatment received on an outpatient basis in a provider’s office or at an alternate facility, including the following:

●  Mental health evaluations

and assessment;

●  Diagnosis;

●  Treatment planning;

●  Referral services;

●  Medication management;

●  Short-term individual,

family and group therapeutic services (including intensive outpatient therapy);

●  Crisis intervention; and

●  Psychological testing.

$35 copay then 100% of eligible expenses.

Any combination of Network and Non-Network Benefits for Mental Health Services and/or Substance Abuse Services is limited to 52 visits per Calendar Year.

Authorization Required

For Network Benefits, referrals to a Mental Health/Substance Abuse provider are at the sole discretion of the Mental Health/Substance Abuse Administrator, who is responsible for coordinating all of your care. Contact the Mental Health/Substance Abuse Administrator regarding Network Benefits for outpatient Mental Health and Substance Abuse Services prior to receiving services.

Without authorization, you will be responsible for paying all charges and no Benefits will be paid.

80% of eligible expenses after satisfying $300 deductible.

Any combination of Network and Non-Network Benefits for Mental Health Services and/or Substance Abuse Services is limited to 52 visits per Calendar Year.

Authorization Required

Referrals to a Mental Health/Substance Abuse provider are at the sole discretion of the Mental Health/Substance Abuse Administrator, who is responsible for coordinating all of your care. Contact the Mental Health/Substance Abuse Administrator regarding Benefits for outpatient Mental Health and Substance Abuse Services prior to receiving services.

Without authorization, you will be responsible for paying all charges and no Benefits will be paid.