Chemical Dependency—80%

Inpatient Admissions Must Be Precertified With the Medical Review Agency (non-Medicare Patients)

Benefits are provided for services and supplies at an approved treatment facility for the effective treatment of chemical dependency. Covered services include: medically necessary detoxification; intensive inpatient treatment, not to exceed 28 days in a 24-month period; intensive outpatient treatment, not to exceed 36 visits in a 24-month period; relapse prevention, not to exceed 12 visits in a 24-month period. No more than three episodes of treatment will be covered in a lifetime. Medically necessary detoxification in a life threatening situation will not count toward the lifetime frequency maximum. If charges for more than these limits are submitted, this plan will not pay those charges. The lifetime maximum applies to services received under the Employee Health Plan and the Retiree Health Plan. These services always require 20 percent coinsurance and these coinsurance expenses do not apply toward the $2,300 annual coinsurance maximum. All non-Medicare patients must precertify inpatient hospital and facility admissions. 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. Benefits for therapeutic and supporting services provided to the patient's family to assist in the patient's diagnosis and treatment are applied to the patient's benefit maximums. (This paragraph has been modified by the revised benefit schedule pursuant to the Patient Protection and Affordable Care Act of 2010. View previous language.)

In situations in which the patient is under court order to undergo an assessment of, or treatment for, chemical dependency, the plan may require the patient to furnish, at his or her expense within 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 patient be treated for that medical condition prior to being admitted for chemical dependency (non-Medicare patients only). In this way, benefits for chemical dependency will be preserved until the patient can fully participate in the program.

Benefits are not provided for:

1. Expenses when a patient is discharged from inpatient care before the prescribed course of treatment is complete, or who voluntarily leaves treatment against medical advice.
2. Expenses when a patient was not examined and diagnosed by a physician or a qualified chemical dependency counselor to have a chemical dependency.
3. Residential treatment centers or services or supplies provided in a residential treatment center; recovery houses which provide an alcohol- or drug-free residential setting; alcohol or drug information and referral services; schools; emergency service patrols; or detoxification, except when the patient 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. Inpatient hospital treatment when that treatment can be provided safely in an outpatient setting without adversely affecting the patient's physical condition.
8. Services, supplies or testing required as a condition of employment.
9. Expenses incurred while the patient is in the custody of, or confined by, any law enforcement officer or agency.