Chemical Dependency – 80%

Benefits are provided for services and supplies at an approved treatment facility for the effective treatment of chemical dependency with a lifetime maximum of $2,500. If expenses exceed this $2,500 lifetime maximum, this plan will not pay the additional costs. All inpatient hospital and facility admissions must be precertified (non-Medicare individuals only). These services always require 20 percent coinsurance and these coinsurance expenses do not apply toward the $2,300 annual coinsurance maximum. Services and supplies received at an approved treatment facility or hospital, including physician’s charges and charges for prescription drugs, are covered only to the extent they are in connection with the effective treatment of chemical dependency. Care at a chemical dependency treatment facility is limited to intensive inpatient treatment and outpatient chemical dependency counseling. Benefits for therapeutic and supporting services provided to the individual’s family to assist in the individual’s diagnosis and treatment are applied to the individual’s benefit maximums.

Outpatient services can be billed in phases. If one phase is completed, the claim for that phase can be submitted.

In situations in which the individual is under court order to undergo an assessment of, or treatment for, chemical dependency, the plan may require the individual to furnish, at his or her expense and no less than 10 and no more than 30 working days before treatment is to begin, an initial assessment of the need for treatment and a treatment plan, prepared by a provider who is a physician or qualified chemical dependency counselor employed by an approved treatment facility to enable the plan to make its own evaluation of medical necessity prior to scheduled treatment.

If there is another medical condition which is serious in nature, the plan, through its medical review agency, may require that the individual be treated for that medical condition prior to being admitted for chemical dependency (non-Medicare individuals only). In this way, benefits for chemical dependency will be preserved until the individual can fully participate in the program.

Benefits are not provided for:

1. Any individual who does not successfully complete the prescribed course of treatment, who is discharged before the prescribed course of treatment is complete, or who voluntarily leaves treatment against medical advice.
2. Any individual who was not examined and diagnosed by a physician or a qualified chemical dependency counselor to have a chemical dependency.
3. Recovery houses which provide an alcohol or drug free residential setting; alcohol or drug information and referral services; residential treatment centers; schools; emergency service patrols; or detoxification, except when the individual immediately (within five days) enrolls in, and successfully completes, a chemical dependency treatment program.
4. Diversional activities such as recreational, hobby or craft equipment, or related fees.
5. Methadone, Antabuse or antagonists, anticravings, or similar drugs in the absence of a treatment program.
6. Services, supplies or drugs for smoking cessation, except as provided for under Tobacco Cessation Program.
7. Ambulance service to or from a treatment facility, hospital or skilled nursing facility.
8. Inpatient hospital treatment when that treatment can be provided safely in an outpatient setting without adversely affecting the individual’s physical condition.
9. Services, supplies or testing required as a condition of employment.