Exclusions and Limitations

No benefits will be payable under the Mental Health and Substance Abuse Benefit for:

  1. Any treatment that has not been precertified by ValueOptions.
  2. Any charge or portion of a charge that is in excess of a reasonable and customary charge.
  3. Any out-of-network treatment provided by a doctor, psychologist or counselor who is not a licensed clinical psychologist, except when a ValueOptions Care Manager approves visits with a Masters-level clinician due to the unavailability of an appropriate in-network provider.
  4. Marriage counseling.
  5. Any out-of-network inpatient confinement in a hospital which does not meet this Plan's definition of a hospital or approved treatment facility for substance abuse (as defined on page 77).
  6. Any charges incurred for a particular type of treatment once a covered person has received benefits for that type of treatment totaling any maximum benefit stated on the Schedule of Benefits during any stated period of time.
  7. Any program of treatment for substance abuse that includes aversion treatment.
  8. Any care or treatment ordered by a judge, court or any court officer unless the care or treatment is determined to be medically necessary and is certified by ValueOptions.
  9. Services which are primarily educational in nature.
  10. Biofeedback.
  11. Any type of expense that is excluded under the Comprehensive Benefit or in the section titled What the Plan Does Not Cover starting on page 72, unless specifically stated as a covered expense under this benefit.