Important Rules Governing Mental Health and Substance Abuse Benefits

  1. Benefits for charges incurred for treatment of substance abuse and mental or nervous disorders are provided ONLY under this benefit. Benefits for these conditions are not payable under the Comprehensive Benefit.
  2. The procedures of the Mental Health and Substance Abuse Review Program must be followed for all treatment of mental health and substance abuse problems. If you do not make the required call or if you make the call but ValueOptions doesn't precertify the treatment plan as medically necessary, no benefits of any kind will be payable for the treatment.
  3. In general, the Plan will pay a greater portion of your costs for mental health and substance abuse services provided by facilities and doctors in the ValueOptions Network.
  4. The facilities and counselors who can provide covered services under the In-Network Schedule on the Schedule of Benefits/Mental Health and Substance Abuse Benefit include a variety of mental health and substance abuse providers not covered under the Out-of-Network Schedule.
    • For coverage under the Out-of-Network Schedule, your care must be provided by a hospital, an approved treatment facility for substance abuse, an M.D. or a licensed clinical psychologist. If no appropriate network provider is available, visits with a Masters-level clinician will be covered if the treatment has been reviewed and approved by a ValueOptions Care Manager. No benefits will be paid for services provided by any other type of mental health or substance abuse provider.
  5. Benefits are payable for the same types of expenses that are covered under the Comprehensive Benefit (see Covered Medical Expenses starting on page 45), but payments are made only according to the maximum benefits and limitations shown on the Schedule of Benefits/Mental Health and Substance Abuse Benefit (pages 9-10).
  6. The limitations and maximums shown on the Schedule of Benefits apply to services provided by in-network and out-of-network providers combined.