Mental
Health/Substance Abuse Care Benefits
Options
A – D and HMO
Mental
Health/Substance Abuse Benefits
for Option HDHP
are listed under Medical Benefits
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Contact
CIGNA Behavioral Health toll-free: 866-726-5267 |
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| Care/Treatment |
Network
Benefits
Member Pays |
Out
of Network |
| Outpatient
Care for Mental Health or Substance Abuse—Group
Visit |
$15
copay per visit
No pre-authorization required
Limit:
50 visits per calendar year, combined total of Group
and Individual visits |
Not
Covered |
| Outpatient
Care for Mental Health or Substance Abuse—Individual
Visit |
$20
copay per visit
No pre-authorization required
Limit:
50 visits per calendar year, combined total of Group
and Individual visits |
Not
Covered |
| Inpatient
Care for Mental Health and Substance Abuse
Hospital Expenses: room and board, X-ray, lab and physician
charges |
10%
of contracted rate (Annual out-of-pocket maximum=$1,000.00)
Limit:
Inpatient Mental Health: 60 days per calendar year
Limit:
Inpatient Substance Abuse: 60 days per calendar
year; 3 episodes of care per lifetime (An episode
of care is any combination of continuously authorized
substance abuse services where there is not a break
of 120 days) |
Not
Covered |
| Detox |
10%
of contracted rate
(Annual out-of-pocket maximum=$1,000.00) |
Not
Covered |
| Outpatient
Laboratory Tests (ordered by a behavioral health provider) |
$0
(covered at 100%) |
Not
Covered |
| Outpatient
Psychological Testing |
$50
copay per visit
(preauthorization required) |
Not
Covered |
|
* Annual
maximum limit of 60 days per person for mental health care;
lifetime maximum limit of 60 days per person for substance
abuse care. |
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Contact
CIGNA HealthCare of California toll-free: 800-CIGNA24 (244-6224) |
| Note:
The mental health/substance abuse benefit information
listed below applies only for Option HMO in Southern California.
To find out if an HMO option is available in your area, please
contact Concordia Plan Services toll-free: 888-927-7526 |
| Care/Treatment |
Network
Benefits
Member Pays |
Out
of Network |
| Outpatient
Visits
Group Therapy |
$15
copay per visit |
Not
Covered |
| Outpatient
Visits
Individual Therapy |
$30
copay per visit
(Combined maximum of 20 visits per calendar year) |
Not
Covered |
| Inpatient
Care
Hospital Expenses: room and board, X-ray, lab,
physician charges, detox, and other inpatient services
and supplies |
$0
(Maximum 30 days per calendar year) |
Not
Covered |
| Intensives
Outpatient Care |
$50
copay per program (Up to 3 programs per year) |
Not
Covered |
| Outpatient
Laboratory Tests |
0% |
Not
Covered |
| Outpatient
Psychological Testing |
0% |
Not
Covered |
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