Benefits for Substance Abuse

IMPORTANT REMINDER - Benefits are payable for treatment of substance abuse ONLY IF the treatment has been precertified by ValueOptions. This requirement also applies to initial evaluations and psychological testing.

Special Rules Applicable to Substance Abuse Treatment

  1. Out-of-Network Calendar Year Deductible - A $250 deductible will be applied to the covered expenses a person incurs each calendar year for out-of-network substance abuse treatment. After the deductible has been satisfied for that year, the Plan will pay its payment percentage of any remaining covered expenses. The deductible applies only once each year to all types of treatment combined. No deductible applies to in-network treatment.
  2. Approved Inpatient Facilities - Benefits will be payable only for out-of-network inpatient treatment that is received in a hospital or an approved treatment facility for substance abuse, including an inpatient facility in the ValueOptions Provider Network.
  3. Treatment Must be Completed - No benefits will be paid for any part of an inpatient or intensive outpatient course of treatment that is terminated before the course of treatment is completed, unless the course of treatment is terminated in order to participate in an outpatient program precertified by ValueOptions.
  4. Weekly Income Benefits - If you are an eligible employee who is receiving approved full-time inpatient treatment, Weekly Income Benefits will be paid until the expiration of that ValueOptions-approved course of treatment, but not beyond the date the treatment is completed. Weekly Income Benefits will not be paid for treatment that is not provided in a hospital or an approved treatment facility (see No. 4 on page 39).

Covered Treatment for Substance Abuse

Benefits for treatment of substance abuse are payable for three types of treatment: inpatient rehabilitative treatment (including inpatient detoxification), intensive outpatient treatment, and regular (non-intensive) outpatient treatment.

  1. Inpatient Rehabilitative Treatment - Each covered person is entitled to up to two inpatient courses of rehabilitative treatment during his lifetime. The two courses of treatment must be separated by at least 180 days. ValueOptions must precertify the number of allowable days of confinement, and benefits will be payable only for the number of days that are precertified by ValueOptions as medically necessary. If ValueOptions precertifies fewer than 21 days, benefits will be payable only for the number of days certified.
    • For in-network treatment, the Plan will pay 80% of the covered expenses incurred.
    • For out-of-network treatment, the Plan will pay 80% of the covered expenses incurred in excess of the calendar year deductible.

    INPATIENT DETOXIFICATION - Treatment for detoxification will be covered ONLY if the detoxification is followed by a completed treatment program that has been precertified by ValueOptions. No benefits are payable for detoxification treatment that begins less than 180 days since the last inpatient treatment.

    • For in-network treatment, the Plan will pay 80% of the covered expenses incurred.
    • For out-of-network treatment, the Plan will pay 80% of the covered expenses in excess of the calendar year deductible.
  2. Intensive Outpatient Treatment - Each covered person is entitled to up to 45 days of intensive outpatient rehabilitative treatment during his lifetime. ValueOptions must precertify the number of allowable days of treatment, and benefits will be payable only for the number of days that are certified by ValueOptions as medically necessary. If ValueOptions certifies fewer than 45 days for a course of treatment, benefits will be payable only for the number of days certified.
    • For in-network treatment, the Plan will pay 90% of the covered expenses.
    • For out-of-network treatment, the Plan will pay 80% of the covered expenses incurred in excess of the calendar year deductible.
  3. Non-Intensive Outpatient Treatment - Covered non-intensive (regular) outpatient treatment may include individual, group and family therapy. The Plan will pay its applicable payment percentage for covered non-intensive outpatient treatment up a maximum of $3,000 per calendar year per person. The $3,000 maximum benefit applies to all in-network and out-of-network treatment combined.
    • For in-network treatment, the Plan will pay 90% of the covered expenses incurred.
    • For out-of-network treatment, the Plan will pay 80% of the covered expenses incurred in excess of the calendar year deductible.