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: $25 copayment per visit

Participating/non-participating: you pay all charges

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

Preferred: Nothing

Participating/non-participating: you pay all charges

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

Preferred: $25 copayment per visit

Participating/non-participating: you pay all charges

• Professional charges for outpatient diagnostic tests

Preferred: Nothing

Participating/non-participating: you pay all charges

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

$25 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.

Maternity-related depression:

We now provide benefits to cover up to 4 mental health visits per year in full for treatment of maternity-related depression when you see a preferred provider.

Nothing