Charges Not Covered in the Behavioral Health Program
Exclusions for expenses incurred in the treatment of mental
illness or chemical dependency include all the services, supplies
and treatments listed as not being covered in the
medical benefits section.
In addition, the following expenses incurred in the treatment
of mental illness or chemical dependency are not covered
under the Plan:
- Experimental treatments or treatments deemed not
medically necessary including, but not limited to,
custodial care for chronic conditions, educational
rehabilitation or treatment of learning disabilities;
- Hospital stays beyond the 30-day maximum per calendar
year, unless approved in advance by the Behavioral Health
Claim Administrator as medically necessary;
- Illness covered by Workers’ Compensation benefits;
- Inappropriate treatment as determined by the Behavioral
Health Claim Administrator;
- Outpatient visits beyond the 60-visit maximum per
calendar year;
- Services in a government hospital or facility for which
no charges are normally made;
- Services, supplies and treatment (including hospitalization)
not approved by a physician as necessary for the
treatment of the covered individual’s behavioral health
condition;
- Services for conditions not attributable to a mental
disorder as defined in the Diagnostic & Statistical
Manual, Version IV (DSM-IV);
- Court-ordered or other externally mandated treatment,
unless such treatment is medically necessary;
- Medications or laboratory services not prescribed,
dispensed or provided within the protocols
established by the Plan’s BehavioralHealth
Claim Administrator;
- Speech therapy;
- Educational, employment and custody evaluations;
- Professional training;
- Services provided by self-help groups;
- Behavioral dysfunctions that result primarily from
organic conditions (e.g., organic brain syndrome,
Alzheimer’s, mental retardation and autism), except
for acute interventions for stabilization of psychiatric
conditions;
- Marriage or stress counseling, except when rendered
in connection with treatment of a DSM-IV mental
disorder;
- Services that would have been paid first by Medicare
for any covered person who failed to enroll in that
program;
- Behavioral treatment that is not medically necessary;
- Treatment for smoking cessation, weight reduction,
obesity, stammering and stuttering;
- Treatment for codependency, except when rendered
in connection with treatment of a DSM-IV
mental disorder;
- Non-abstinence based and nutritionally based
chemical dependency treatment except when
medically necessary;
- Treatment for sexual addiction, except when rendered
in connection with treatment of a DSM-IV mental
disorder;
- Treatment of chronic pain, except when rendered
in connection with treatment of a DSM-IV
mental disorder;
- Treatment or consultations provided by the person’s
parents, siblings, children, spouse, former spouse or
domestic partner; and
- Ambulance services or other transportation, except
when medically necessary and pre-approved by the
Plan’s BehavioralHealth Claim Administrator.
However, pre-approval is not necessary in the case
of an emergency.
If you have questions about the mental
health and substance abuse benefits or
required approvals or to determine if a
particular expense is covered, you can
call ComPsych directly at the toll-free
number shown on the Resources chart
in the Administration Information
section of this SPD.
