How Mental Health and Alcohol/Substance Abuse Benefits Work

For More Information …

… about your mental health or alcohol/substance abuse benefits, contact Pequot Plus Health Benefit Services at 1-888-779-6872. To pre-certify mental health or alcohol/substance abuse treatment, call the number listed on your benefit card.

The PPO Plan makes a distinction between inpatient and outpatient mental health and alcohol/substance abuse care and provides different benefits for each type of care. Inpatient and outpatient benefits have limits on care, generally based on the number of days of inpatient care.

Please note that all inpatient mental health and alcohol/substance abuse treatment must be pre-certified by calling the number listed on your benefit card before you receive treatment.

The following is a brief summary of your mental health and alcohol/substance abuse benefits.

Mental Health Benefits

Inpatient and partial levels of care require pre-certification.

Mental Health Benefits – PPO Advantage Plan
	In-Network Benefits	Out-of-Network Benefits
Outpatient Treatment	$25 copay per visit, no deductible	30% of U&C after deductible
Inpatient Treatment (Up to 120 days maximum annually, combined with Inpatient Medical Benefit maximum)	$250 copay per admission, plus 10% after deductible	$250 copay per admission, plus 30% of U&C, after deductible
Partial Hospital and Intensive Outpatient Treatment (Up to 120 days maximum annually, combined with Inpatient Medical Benefit maximum)	$250 copay per admission, plus 10% after deductible No copay if transferred from inpatient	$250 copay per admission, plus 30% of U&C, after deductible No copay if transferred from inpatient
Testing (Not educational in nature)	10% after deductible	30% of U&C, after deductible

Mental Health Benefits – PPO Choice Plan
	In-Network Benefits	Out-of-Network Benefits
Outpatient Treatment	$35 copay per visit, no deductible	50% of U&C after deductible
Inpatient Treatment (Up to 120 days maximum annually, combined with Inpatient Medical Benefit maximum)	$250 copay per admission, plus 30% after deductible	$250 copay per admission, plus 50% of U&C, after deductible
Partial Hospital and Intensive Outpatient Treatment (Up to 120 days maximum annually, combined with Inpatient Medical Benefit maximum)	$250 copay per admission, plus 30% after deductible No copay if transferred from inpatient	$250 copay per admission, plus 50% of U&C, after deductible No copay if transferred from inpatient
Testing (Not educational in nature)	10% after deductible	50% of U&C, after deductible

Alcohol/Substance Abuse Benefits

Inpatient and partial levels of care require pre-certification.

Alcohol/Substance Abuse Benefits – PPO Advantage Plan
	In-Network Benefits	Out-of-Network Benefits
Outpatient Treatment	$25 copay per visit	30% of U&C after deductible
Inpatient Treatment (Up to 120 days maximum annually, combined with Inpatient Medical Benefit maximum)	$250 copay per admission plus 10%, after deductible	$250 copay per admission, plus 30% of U&C after deductible
Partial Hospital and Intensive Outpatient Treatment (Up to 120 days maximum annually, combined with Inpatient Medical Benefit maximum)	$250 copay per admission plus 10%, after deductible No copay if transferred from inpatient	$250 copay per admission, plus 30% of U&C after deductible No copay if transferred from inpatient
Testing (Not educational in nature)	10% after deductible	30% of U&C after deductible

Alcohol/Substance Abuse Benefits – PPO Choice Plan
	In-Network Benefits	Out-of-Network Benefits
Outpatient Treatment	$35 copay per visit	50% of U&C after deductible
Inpatient Treatment (Up to 120 days maximum annually, combined with Inpatient Medical Benefit maximum)	$250 copay per admission plus 30%, after deductible	$250 copay per admission, plus 50% of U&C after deductible
Partial Hospital and Intensive Outpatient Treatment (Up to 120 days maximum annually, combined with Inpatient Medical Benefit maximum)	$250 copay per admission plus 30%, after deductible No copay if transferred from inpatient	$250 copay per admission, plus 50% of U&C after deductible No copay if transferred from inpatient
Testing (Not educational in nature)	30% after deductible	50% of U&C after deductible

Cause Defined

“Cause” is defined by the PPO Plan as a continuous treatment prescribed within a clinical treatment plan following an initial admission until the end of the treatment episode.

Inpatient Treatment

Charges for an inpatient facility are limited to the semi-private room rate. Inpatient treatment must be pre-certified by the medical utilization company. Please see “Pre-Certification” in the Preferred Provider Organization section.