Outpatient Hospital or Other Covered Facility

2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(e). Mental Health and Substance Use Disorder Benefits

Benefit Description

Outpatient Hospital or Other Covered Facility
Outpatient services provided and billed by a covered facility

Diagnostic tests
Group psychotherapy
Individual psychotherapy
Intensive outpatient treatment
Partial hospitalization
Pharmacologic (medication) management
Psychological testing

Note: We cover outpatient mental health and substance use disorder services or supplies provided and billed by residential treatment centers at the levels shown here. Prior approval is required. Failure to obtain prior approval will result in a $100.00 penalty. See page 22.

You Pay
Preferred facilities: 30% of the Plan allowance

Non-preferred (Member/Non-member) facilities: You pay all charges

Benefit Description
Not covered:

Marital, family, educational, or other counseling or training services
Services performed by a non-covered provider
Testing for and treatment of learning disabilities and intellectual disability
Inpatient services performed or billed by residential treatment centers, except as described on pages 79 and 89
Services performed or billed by schools, halfway houses, group homes or members of their staffs
Note: We cover professional services as described on page 16 when they are provided and billed by a covered professional provider acting within the scope of his or her license.
Psychoanalysis or psychotherapy credited toward earning a degree or furtherance of education or training regardless of diagnosis or symptoms that may be present
Services performed or billed by residential therapeutic camps (e.g., wilderness camps, Outward Bound, etc.)
Light boxes
Custodial or long term care (see Definitions)

You Pay
All charges

List Item:
mental
health
facility
substance
disorder
outpatient
hospital
diagnostic
tests
facilities
psycotherapy
group
individual
intensive
treatment
therapy
pharmacologic
medication
management
psychological
prior
approval
failure
marital
family
education
counseling
training
non-covered
testing
disability
intellectual
learning
residential
inpatient
schools
halfway
houses
homes
psychoanalysis
therapeutic
camps
wilderness
ourward
custodial
penalty