When Do Psychiatric and Substance Abuse Treatment Network Benefits Apply

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How Do You Receive Professional Care
How Do You Receive Emergency Care
How Is Administration Reduced

Managed Choice POS provides a separate network for psychiatric and substance abuse treatment through Value Options. [Please note: not all retirees have this benefit.] Benefits for psychiatric and substance abuse treatment are paid only if you use this network.

To receive benefits for psychiatric and substance abuse treatment:

You first call the Value Options toll-free number when you or an enrolled dependent needs help. Call before you seek care. Unless you call Value Options first, no benefits will be paid.
A trained mental health Clinical Case Manager will consult with you to determine your needs and, if necessary, refer you to the appropriate provider for Professional Care. The Clinical Case Manager will monitor and review your treatment.

Emergencies require fast response that may not allow you to call the toll-free number in advance. In such cases, there is an Emergency Care process.

Only covered services are eligible for benefits.

You do not choose a Primary Care Physician for this network.

If you are hospitalized for treatment of a psychiatric or substance abuse disorder, and while in the hospital you are also diagnosed and treated for a medical problem not related to your primary diagnosis, Value Options will coordinate arrangements for your care and coverage with Blue Cross Blue Shield of Illinois, if necessary.

How Do You Receive Professional Care

Only professional care arranged through the network will be eligible for benefits. The types of covered professional care include:

Inpatient treatment
Outpatient treatment
Intermediate treatment such as partial hospital and residential programs
Prescription drugs
X-ray and laboratory charges
Other medically related charges.

When you or a covered family member needs assistance, call the toll-free number. The calls are answered 24 hours a day, seven days a week.

You will be asked to provide the following information:

Employee's name and Social Security number
Patient's name, sex and date of birth
Employer's name.

The Clinical Case Manager will discuss your problem confidentially and refer you to a professional in your area for treatment when necessary. If you use the provider to whom you are referred, you will pay $10 for each office visit. If you do not use this provider, no benefits will be paid.

Drugs prescribed by a Value Options provider for psychiatric and substance abuse treatment are covered as follows:

You must have your prescriptions filled at a Caremark participating pharmacy. You will pay a $7 copayment. If you do not use a Caremark participating pharmacy, the prescriptions will not be covered.

If you have a Flexible Spending health care account, you can receive pretax reimbursement for your copayments by filing a Flexible Spending Account claim.

You should present your ID card to the provider at the time care is received. Your card identifies you as eligible for Managed Choice POS benefits for the psychiatric and substance abuse network and includes the toll-free number. The provider may call that number to verify your coverage.

If you choose to receive care other than that approved by the Value Options network, no benefits will be payable, and you will be responsible for the full cost of the treatment.

How Do You Receive Emergency Care

The plan covers you for emergency care wherever the emergency occurs. An emergency exists when an individual is in significant distress and is:

Significantly dysfunctional or
A threat to the safety of himself or herself or another person.

In an emergency:

The patient should go to the nearest emergency facility immediately. You should not jeopardize yourself or others by waiting to make a phone call if the situation is clearly dangerous.
The patient, a family member, or a friend must call Value Options within 24 hours, using the toll-free number.
Treatment at the facility approved by Value Options will be eligible for benefits.

The Clinical Case Manager will discuss the treatment plan with the emergency facility and, to approve or continue benefits, the Case Manager may specify other types of care.

If you do not call Value Options within 24 hours, the treatment may not be approved for benefits. Whenever you use an emergency facility, present your ID card. This card contains emergency instructions and the toll-free number.

Ambulance service is covered for emergency transportation to the nearest hospital where adequate care can be provided.

How Is Administration Reduced

With the Managed Choice POS psychiatric and substance abuse network, your paperwork is kept to a minimum. In most cases, you will file no claims for benefits. The network provider should take care of the claims processing.

If you receive a bill for approved services, call Value Options immediately. Use the same toll-free number you called to receive care. Value Options will give you instructions for handling the billing at that time.