Lactation Counseling & Equipment No Charge No adjustment Service Standard Benefit Enhanced Benefit Acupuncture Treatment (Limited to post-procedure nausea, pain and vomiting due to surgery, anti-neoplastic agents, or postoperative dental pain.) Cardiac Rehabilitation Preauthorization Required for Phase III and Phase IV) Chemotherapy (Pre-Authorization Required) Chiropractic Care/Spinal Manipulations (30 visit limit per Plan Year. Collaborative Care may be able to waive the limitation.) $150 Copayment per Date of Service Collaborative Care may be able to extend the visit limitation Dialysis (Hemodialysis, Peritoneal Dialysis, Coordination of Billing and Supplies for Home Based Dialysis) Holistic or Homeopathic Medicine Not Covered No adjustment Hyperbaric Treatment (Must be Pre-authorized.) Infusion Specialty Medications (Must be Pre-Authorized. If purchased through the Prescription Plan, other rules may be applicable. See section VII- Prescription Drug Benefits) Infusion Therapy Not Specific to Cancer (Must be Pre-Authorized.) Massage Therapy Not Covered No adjustment Physical, Speech, Occupational Therapy, CBA, CBT, and ABA (Combined 30 visit limits per Plan Year. Collaborative Care may be able to waive the limitation in cases where treatment in lieu of this care is considered more advanced or invasive for the member.) $150 copayment per provider, per date of service, limited to 240 minutes of billable care per date of service. Collaborative Care may be able to reduce member cost share Pulmonary Rehab/Respiratory Therapy (30 visit limit per Plan Year. Collaborative Care may be able to waive the limitation) Vision Therapy (Up to 12 visits per calendar year, Subject to Medical Necessity. Preauthorization Required) Service Standard Benefit Enhanced Benefit Office Visit - Mental Health (Clinic Based) Inpatient Mental Health Services (Facility. Must be Pre-Authorized.) Inpatient Mental Health Services (Physician) No Charge, as long as services are received during a covered inpatient stay Collaborative Care may be able to reduce member cost share Other Physician Services (Including pathology & radiology services) Outpatient Mental Health Services (Including Psychotherapy, other therapies, testing. Facility Based) $500 Copayment per provider, per date of treatment Collaborative Care may be able to reduce member cost share Outpatient Mental Health Services (Physician / Practitioner) $150 Copayment per provider, per date of treatment Collaborative Care may be able to reduce member cost share Mental Health Residential Treatment (Facility & Physician. Must be Pre-Authorized.) $2,000 Copayment per confinement Collaborative Care may be able to reduce member cost share Mental Health Partial Hospitalization (Facility & Physician. Must be Pre-Authorized.) $2,000 Copayment per confinement Collaborative Care may be able to reduce member cost share Service Standard Benefit Enhanced Benefit Office Visit - Substance Abuse or Alcohol Abuse $150 Copayment per Provider, per Date of Service Collaborative Care may be able to reduce member cost share Inpatient Alcohol Detox (Facility. Must be Pre-Authorized.) Inpatient Alcohol Detox $100 Copayment per Date of Service Collaborative Care may be able to reduce member cost share No Charge Collaborative Care may be able to reduce member cost share Therapy and Rehabilitation Services - Office / Stand Alone Clinic Typically Excluded, but if approved by Collaborative Care, $150 Copayment per Date of Service No adjustment $150 Copayment per Date of Service Collaborative Care may be able to reduce member cost share $150 Copayment per Date of Service Collaborative Care may be able to reduce member cost share $150 Copayment per Date of Service Collaborative Care may be able to reduce member cost share $150 Copayment per Date of Service No adjustment $200 Copayment per Date of Service Collaborative Care may be able to reduce member cost share $2,000 Copayment per admission Collaborative Care may be able to reduce member cost share $0 included with inpatient facility admission copay Collaborative Care may be able to reduce member cost share Substance Abuse (Including Alcohol) $2,000 Copayment per admission Collaborative Care may be able to reduce member cost share $75 Copayment per Date of Service Collaborative Care may be able to reduce member cost share Mental Health Services $150 Copayment per Provider, per Date of Service Collaborative Care may be able to reduce member cost share No Charge, as long as services are received during a covered inpatient stay Collaborative Care may be able to reduce member cost share