MHN Provider/Facility	Non-Network Provider/Facility
ALCOHOL OR DRUG ABUSE*
Chemical Dependency Plan Benefits	Plan pays 90% of chemical dependency treatment up to a maximum of $12,500 per episode, after $150 deductible per episode. An Episode is defined as any continuous course of treatmentthat focuses on a particular occurrence of a chemical dependency problem.** Lifetime maximum - 2 episodes per person (including Detox).	Plan pays 50% of chemical dependency treatment up to a maximum of $12,500 per episode, after a $500 deductible per episode. An Episode is defined as any continuous course of treatmentthat focuses on a particular occurrence of a chemical dependency problem.** Lifetime maximum - 2 episodes per person (including Detox).
Inpatient / Alternate Care	Treatment limited to a maximum of 30 days. (including Detox), per episode, up to the $12,500 per episode maximum.	Treatment limited to a maximum of 30 days of inpatient/alternate treatment, (including Detox), per episode, up to the $12,500 per person maximum.
Residential Treatment	Residential Treatment - 2 days of Residential Treatment are equal to 1 day of Inpatient Treatment. Residential Treatment days in combination with Inpatient and Partial treatment cannot exceed a maximum of 30 days per Episode of Treatment.	See benefit above.
Partial Treatment	Partial Treatment - 2 days of Partial Treatment are equal to 1 day of Inpatient Treatment. Partial Treatment days in combination with Inpatient and Residential treatment cannot exceed a maximum of 30 days per Episode of Treatment.	See benefit above.
Intensive Outpatient Treatment	Intensive Outpatient Treatment - 3 days of Intensive Outpatient Treatment are equal to 1 day of Inpatient Treatment. Partial Treatment days in combination with Inpatient, Partial, and Residential Treatment cannot exceed a maximum of 30 days per Episode of Treatment.	See benefit above.
Substance Abuse Professional (SAP) Services	SAP Services are provided to eligible active employee participants that fail DOT Alcohol or Drug Test	No Substance Abuse Professional (SAP) Services

 

	MHN Provider/Facility	Non-Network Provider/Facility
MENTAL HEALTH*
Assessment	Maximum 3 individual assessment sessions per eligible participant per calendar year. Plan pays 100%	No Individual Assessment Benefit. Covered under Outpatient Benefit.
Outpatient	Plan pays maximum of 50 authorized combined Individual/Group Sessions per calendar year. Individual Sessions - You Pay: $0.00 for visits 1 - 5 $10.00 for visits 6 - 10 $20.00 for visits 11 - 15 $30.00 for visits 16 - 50 Group Sessions - You Pay Nothing The maximum number of sessions per person per calendar year cannot exceed 50 for combined in and out-of-network.	Plan pays 50% of allowed charges for a maximum of 50 Individual/Group Sessions per calendar year. The maximum number of sessions per person per calendar year cannot exceed 50 for combined in and out-of-network.
Inpatient / Alternate Care	Plan pays 100% of authorized inpatient treatment to a maximum of 45 days per eligible participant per calendar year. Lifetime maximum is 90 days.	Plan pays 50% of the allowed charges to a maximum of 45 days of inpatient/alternate care per calendar year. Lifetime maximum is 90 days.
Residential Treatment	Residential Treatment - 2 days of Residential Treatment are equal to 1 day of Inpatient Treatment. Residential Treatment days in combination with Inpatient and Partial Treatment cannot exceed a maximum of 45 days per calendar year and 90 days per individual per lifetime.	See benefit above.
Partial Treatment	Partial Treatment - 2 days of Partial Treatment are equal to 1 day of Inpatient Treatment. Partial Treatment days in combination with Inpatient and Residential Treatment cannot exceed a maximum of 45 days per calendar year and 90 days per individual per lifetime.	See benefit above.

This summary is a brief overview of benefits only. For more detailed descriptions of your benefits and their exclusions refer to this Web Site or the insurance contract.

^*Plan maximums include in and out-of-network treatment combined.