• Services must be provided by a PPO provider to receive In-Network benefits.


• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.


• We have a separate calendar year deductible of $250 per person ($500 per family) under the High Option and $300 per person ($600 per family) under the Standard Option which applies to almost all benefits for the treatment of mental health and substance abuse. For example, doctors' inpatient hospital visits for a physical illness or disease applies to the Plan's regular calendar year deductible. If the services are rendered to treat mental health or substance abuse, the separate mental health and substance abuse calendar year deductible applies. We added "(No deductible)" to show when a deductible does not apply.


• Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.


• YOU MUST GET PREAUTHORIZATION FOR THESE SERVICES. See the instructions after the benefits descriptions below.


• In-Network mental health and substance abuse benefits are below, then Out-of-Network benefits begin on page 51.

All diagnostic and treatment services contained in a treatment plan that we approve. The treatment plan may include services, drugs, and supplies described elsewhere in this brochure. Note: In-Network benefits are payable only when we determine the care is clinically appropriate to treat your condition and only when you receive the care as part of a treatment plan that we approve.

• Outpatient professional services by providers such as psychiatrists, psychologists, or clinical social workers including:
  
  
  • individual or group therapy
  
  
  • collateral visits with members of the patient's immediate family
  
  
  • convulsive therapy visits


• Medication management

Note: Preauthorization is required; see page 50.

• Day or after care (partial hospitalization) in a hospital

Note: Preauthorization is required; see page 50.

• Diagnostic tests

• Room and board, including general nursing care, in semiprivate accommodations


• Other charges for hospital services and supplies (other than professional services) including but not limited to the use of operating, treatment and recovery rooms; X-rays; surgical dressings; and drugs and medicines

Note: Precertification is required for an inpatient confinement; see page 50. A confinement is defined in Section 10, page 74.

$200 copayment per confinement, nothing for room and board and 10% of the Plan allowance for other hospital services (No deductible)

$200 copayment per confinement, nothing for room and board and 15% of the Plan allowance for other hospital services (No deductible)

• Services of a doctor for inpatient hospital visits

10% of the Plan allowance

15% of the Plan allowance

Not covered:

• Marital counseling


• Treatment for learning disabilities


• Telephone consultations and/or therapy


• On-line consultations


• Travel time to the patient's home to conduct therapy


• Services we have not approved.

Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.

All charges

All charges

To be eligible to receive these enhanced mental health and substance abuse benefits you must obtain a treatment plan and follow all of the following network authorization processes:

• The medical necessity of your admission to a hospital or other covered facility must be preauthorized prior to admission. Emergency admissions must be reported within two business days following the day of admission even if you have been discharged. Otherwise, benefits will be reduced by $500.


• Prior authorization is required for outpatient treatment and day or after care treatment (partial hospitalization). In order to maximize your benefits, your provider must submit a treatment plan to CIGNA/CareAllies prior to your 9th outpatient visit. In determining when your treatment plan must be submitted, we count all outpatient psychotherapy visits, even if you use different providers. When we approve the treatment plan, we will give your provider authorization for additional visits. If you change providers, a new treatment plan must be submitted. If prior authorization is not obtained, we will reduce our Plan allowance by 20%.

Note: To obtain preauthorization call CIGNA/CareAllies at 1-800/887-9735.

We will cover the office visit fee for therapy sessions rendered by providers such as psychiatrists, psychologists, or clinical social workers.

Therapy sessions include:

• Office visits, group therapy, and collateral visits with members of the patient's immediate family


• Medication management

Other outpatient care includes:

• Convulsive therapy visits, and


• Day or after care (partial hospitalization) in a hospital

Note: Almost all benefits for the treatment of mental health and substance abuse require precertification, see page 52. During the precertification process, we may establish an approved treatment plan.

30% of the Plan allowance and any difference between our allowance and the billed amount

30% of the Plan allowance and any difference between our allowance and the billed amount

• Diagnostic tests

30% of the Plan allowance and any difference between our allowance and the billed amount

30% of the Plan allowance and any difference between our allowance and the billed amount

Covered inpatient hospital and rehabilitation facility charges include:

• Room and board including general nursing care, in semiprivate accommodations


• Other charges for hospital services and supplies (other than professional services) including but not limited to the use of operating, treatment and recovery rooms; X-rays; surgical dressings; and drugs and medicines

Note: Precertification is required for an inpatient confinement, see page 52.

$300 copayment per confinement plus 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

$300 copayment per confinement plus 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

• Services of a doctor for inpatient hospital visits

30% of the Plan allowance and any difference between our allowance and the billed amount

30% of the Plan allowance and any difference between our allowance and the billed amount

Not covered out-of-network:

• The same exclusions contained in this brochure that apply to other benefits apply to mental health and substance abuse benefits. OPM's review of disputes about out-of-network treatment plans will be based on the treatment plan's clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.


• Marital counseling


• Treatment for learning disabilities


• Telephone consultations and/or therapy


• On-line consultations


• Travel time to the patient's home to conduct therapy


• Services rendered or billed by schools, residential treatment centers or halfway houses or members of their staffs

To be eligible to receive mental health and substance abuse benefits you must follow your treatment plan and all of our authorization processes. These include obtaining prior authorization for:

• The medical necessity of your admission to a hospital or other covered facility prior to admission. Emergency admissions must be reported within two business days following the day of admission even if you have been discharged. Otherwise, benefits will be reduced by $500. See Section 3 for details.


• Outpatient treatment and day or after care treatment (partial hospitalization). In order to maximize your benefits, your provider must submit a treatment plan to CIGNA/CareAllies prior to your 9th outpatient visit. In determining when your treatment plan must be submitted, we count all outpatient psychotherapy visits, even if you use different providers. When we approve the treatment plan, we will give your provider authorization for additional visits. If you change providers, a new treatment plan must be submitted. If prior authorization is not obtained, we will reduce our Plan allowance by 20%.

• Section 4, Your cost for covered services, for information about catastrophic protection for these benefits.


• Section 7, Filing a claim for covered services, for information about submitting out-of-network claims.