Benefit Plans - Standard Option - Mental Health and Substance Abuse

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Mental Health and Substance Abuse

Standard Option includes coverage for mental health and substance abuse treatments. Your cost-sharing responsibilities are no greater for these treatments than for other illnesses or conditions. Standard Option offers you the flexibility to choose to receive care by an in-network, Preferred provider or by an out-of-network, Non-preferred provider.

Outlined below is a summary of the mental health and substance abuse benefits provided under Standard Option. Please remember that all benefits are subject to the definitions, limitations, and exclusions defined in the 2010 Blue Cross and Blue Shield Service Benefit Plan brochure.

2010 Standard Option - Mental Health and Substance Abuse Benefits

What You Pay

Services	Standard Option PPO Benefit	Standard Option Non-PPO Benefit*
Inpatient Hospital — Precertification required	$200 per admission copayment Unlimited days	Member: $350 per admission copayment for unlimited days (No deductible) Non-member: $350 per admission copayment for unlimited days, plus 35% of the Plan allowance, and any remaining balance after our payment (No deductible)
Outpatient Facility Care **	Subject to the calendar year deductible (Individual or Family) 15% of the Preferred Provider Allowance	Subject to the calendar year deductible (Individual or Family) 35% of the Plan Allowance at Member facilities and Non-member facilities
Inpatient Professional Care	Subject to the calendar year deductible (Individual or Family) 15% of the Preferred Provider Allowance	Member facility: $350 per admission copayment for unlimited days (No deductible) Non-member facility: $350 per admission copayment for unlimited days, plus 35% of the Plan allowance, and any remaining balance after our payment (No deductible) Participating professional: 35% of the Plan allowance Non-participating professional: 35% of the Plan allowance, plus any difference between our allowance and the billed amount
Outpatient Professional Care **	$20 office visit copayment for primary care provider 30 office visit copayment for specialists	Subject to the calendar year deductible (Individual or Family) 35% of the Plan Allowance

Services

Standard Option PPO Benefit

Standard Option Non-PPO Benefit*

Inpatient Hospital — Precertification required

$200 per admission copayment

Unlimited days

Member: $350 per admission copayment for unlimited days (No deductible)

Non-member: $350 per admission copayment for unlimited days, plus 35% of the Plan allowance, and any remaining balance after our payment (No deductible)

Outpatient Facility Care **

Subject to the calendar year deductible (Individual or Family)

15% of the Preferred Provider Allowance

Subject to the calendar year deductible (Individual or Family)

35% of the Plan Allowance at Member facilities and Non-member facilities

Inpatient Professional Care

Subject to the calendar year deductible (Individual or Family)

15% of the Preferred Provider Allowance

Member facility: $350 per admission copayment for unlimited days (No deductible)

Non-member facility: $350 per admission copayment for unlimited days, plus 35% of the Plan allowance, and any remaining balance after our payment (No deductible)
Participating professional: 35% of the Plan allowance

Non-participating professional: 35% of the Plan allowance, plus any difference between our allowance and the billed amount

Outpatient Professional Care **

$20 office visit copayment for primary care provider

30 office visit copayment for specialists

Subject to the calendar year deductible (Individual or Family)

35% of the Plan Allowance

* When you use Non-member facilities and Non-participating professionals, you are also responsible for the difference between the provider's charge and the Plan Allowance.

** You must call us for prior approval of outpatient mental health or substance abuse care before receiving any outpatient professional or outpatient facility services.

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