In Detail... (cont'd)

MENTAL HEALTH AND SUBSTANCE ABUSE TREATMENT

Please click on the link below to access the Value Options website for information regarding Mental Health and Substance Abuse. https://www.achievesolutions.net\vought

If you are enrolled in the Comprehensive PPO, Standard PPO, Safety Net PPO, the POS plan option or an HMO in the Dallas/Fort Worth area, then ValueOptions administers your mental health and substance abuse benefits. The ValueOptions provider network is separate from the Blue Cross Blue Shield network.

ValueOptions is experienced in managing inpatient hospital and outpatient counseling and therapy for mental health conditions and substance abuse. The nationwide network of clinicians includes psychiatrists, psychologists, and independently licensed master's-level therapists.

When you need mental health or substance abuse treatment, first contact ValueOptions at 1-866-269-5800 for approval -even if you do not plan to use a network provider.

If you do not contact Value Options for pre-approval of in- or out-of-network care, the mental health and substance abuse program pays no benefits except in an emergency. If you are enrolled in the POS option, you need to obtain approval for mental health and substance abuse care through Value Options - not through your PCP.

Note: Remember, in an emergency, seek immediate care and call ValueOptions within 72 hours. Your call is confidential. No one at Vought Aircraft will be told about your call or about any treatment you receive, unless authorized by you or required by law.

Medically Necessary

The Vought Aircraft mental health and substance abuse program pays for medically necessary and appropriate mental health and substance abuse services and treatments. For benefits to be considered medically necessary by the claims administrator, the service or treatment must be:

• Adequate and essential for your condition
  
• Expected to improve your condition or level of functioning.

The fact that your physician prescribes, orders, recommends or approves a service or supply does not make it medically or psychologically necessary. That determination is made by the claims administrator.

Pre-Approval Is a Must!

Without pre-approval the plan pays no benefits. Wherever you are, ValueOptions can help you find a provider. In addition, you must contact ValueOptions for approval before treatment begins. If no ValueOptions provider is available when you receive pre-approval, ValueOptions refers you to an out-of-network provider and the mental health and substance abuse program pays in-network benefits.

Receiving Care

Follow these steps to receive care through ValueOptions.

1. Call ValueOptions at 1-866-269-5800 and identify yourself as a Vought Aircraft employee or enrolled family member.
   
2. Give the ValueOptions case manager your address, telephone number, the employee's Social Security number, and the name, sex, and birth date of the patient.
   
3. Discuss the situation with the ValueOptions; case manager, who will refer you to a local ValueOptions network provider or to an EAP counselor.
   
4. Call to make an appointment with the network provider (or an out-of-network provider).
   
5. Inform your provider that ValueOptions administers your mental health and substance abuse benefits.
   
6. Ensure your claim is properly filed. Network providers file claims for you. Out-of-network providers may ask you to pay expenses up front. in that case, you need to file a claim with ValueOptions for reimbursement. Claim forms are available from ValueOptions.
   
7. If you are enrolled in the POS option, contact your PCP if your ValueOptions prsovider refers you for any medical services, such as laboratory work. Your PCP needs to coordinate your medical services for you to receive in-network medical plan benefits. Otherwise, you receive out-of-network benefits, and the POS option pays 70% of eligible expenses after you pay the benefit plan year deductible.

Emergency Treatment

If you or your enrolled family member needs emergency mental health or substance abuse treatment, call Value Options at 1-866-269-5800. An on-call case manager is available 24 hours a day, seven days a week.

If you or an enrolled family member is hospitalized because of a mental health emergency and is unable to precertify the admission, a family member, physician or friend should call ValueOptions within 72 hours after the admission.

Once the person hospitalized becomes stable, ValueOptions; may advise a transfer to a network hospital to receive the highest level of benefit reimbursement.

Treatment of medical emergencies related to alcoholism or substance abuse, such as overdose, coma, shock, or a heart attack, is covered under the Comprehensive PPO, Standard PPO, Safety Net PPO and POS options as well as some HMOs. File claims for these expenses with Blue Cross Blue Shield or your HMO.

Eligible Mental Health and Substance Abuse Expenses

The Vought Aircraft mental health and substance abuse program pays for a wide range of inpatient and outpatient services. Covered mental health/substance abuse expenses and services are as follows:

• Charges for medically necessary licensed local ambulance service to or from the nearest hospital or approved qualified mental health/substance abuse treatment facility where the needed mental health treatment or evaluation can be provided, as authorized by ValueOptions.
  
  
• Medically necessary outpatient charges at a hospital or approved qualified mental health/substance abuse treatment facility
  
  
• The services of qualified mental health/substance abuse treatment providers, as determined by ValueOptions, who provide services within the lawful scope of the practice of:
  
  • Psychiatrists
    
  • Licensed or registered psychologists
    
  • Licensed or registered psychotherapists
    
  • Licensed or registered psychiatric social workers.
    
    
• Semiprivate room and board charges, and medically necessary inpatient services and supplies at a hospital or qualified mental health/substance abuse treatment facility approved by ValueOptions.

Ineligible Mental Health and Substance Abuse Expenses

Some mental health and substance abuse services and treatments are not eligible:

• Aversion therapy
  
  
• Services or treatment rendered by you, your spouse or your child, or by your parent, parent-in-law, brother, sister, brother-in-law or sister-in-law.
  
  
• Conditions resulting from: - Act of war (declared or undeclared) - Insurrection - Atomic explosion - Other release of nuclear energy under any conditions (except when used solely as a medical treatment).
  
  
• Counseling/therapy related to a sex change.
  
  
• Couples therapy, except when certified as a medically necessary part of the treatment plan of a spouse with a Diagnostic and Statistical Manual of Mental Disorders (DSM III-MV) mental disorder that is covered under the mental health and substance abuse program.
  
  
• Court-ordered psychiatric or substance abuse treatment, except when certified by ValueOptions as medically necessary.
  
  
• Custodial care.
  
  
• Educational rehabilitation or treatment of leaming disabilities, regardless of the setting in which services are provided.
  
  
• Evaluations, consultations, or therapy for educational or professional training or for investigational purposes relating to employment.
  
  
• Experimental or investigational services or supplies. Any of the following criteria may be cause for classification as experimental or investigational:
  
  • Lack of federal or other govemmental body approval, such as drugs and devices that do not have unrestricted market approval from the Food and Drug Administration (FDA) or final approval from any other govemmental body for use in treatment of a specified condition. Any approval that is granted as an interim step in the regulatory process is not a substitute for final or unrestricted market approval
    
  • Insufficient or inconclusive scientific evidence in peerreviewed medical literature to permit the plan's evaluation of the therapeutic value of the service or supply
    
  • Inconclusive evidence that the service or supply has a beneficial effect on health outcomes
    
  • Evidence that the service or supply is not as beneficial as any established alternatives
    
  • Insufficient information or inconclusive scientific evidence that, when used in a noninvestigational setting, the service or supply has a beneficial effect on health outcomes and is as beneficial as any established altematives.
    
    
• Injuries or illnesses caused by the conduct or omission of a third party for which you have a claim for damages or relief, unless you provide ValueOptions with a lien against such claim for damages or relief.
  
  
• Marriage counseling except through your EAP.
  
  
• More than two inpatient admissions for substance abuse treatment at an in- or out-of-network facility
  
  
• Non-abstinence-based or nutritionally based treatment for substance abuse.
  
  
• Prescription drugs; however, your prescription may be eligible under the Vought Aircraft medical plan prescription drug benefits.
  
  
• Private duty nursing, except when pre-approved by ValueOptions as medically necessary.
  
  
• Psychological testing, except when pre-approved by ValueOptions as medically necessary.
  
  
• Remedial education beyond evaluation and diagnosis of learning disabilities, education rehabilitation, academic education, and educational therapy for learning disabilities.
  
  
• Services, supplies or treatment covered under the Vought Aircraft medical plan options.
  
  
• Services to treat conditions not attributable to a mental disorder but as additional conditions that may be a focus of clinical attention, such as V Codes (i.e., those identified by the DSM III-R/IV).
  
  
• Services, treatment or supplies provided as a result of any workers' compensation law or similar legislation.
  
  
• Services, treatment or supplies obtained through, or required by, any governmental agency or program, whether federal, state, or any subdivision thereof (exclusive of Medicaid/Medi-Cal).
  
  
• Sex therapy programs.
  
  
• Therapies that do not meet national standards for mental health professional practice, including - but not limited to -Erhard/The Forum, primal therapy, Rolfing, sensitivity training, bioenergetic therapy, and crystal healing therapy
  
  
• Treatment by any providers not pre-approved by the claims administrator.
  
  
• Treatment for caffeine or nicotine addiction, withdrawal or dependence.
  
  
• Treatment for co-dependency
  
  
• Treatment for personal or professional growth, development, training, or professional certification.
  
  
• Treatment of congenital and/or organic disorders (e.g., autism, mental retardation) except for associated treatable and acute behavioral manifestations.
  
  
• Treatment or consultations provided by telephone.