First Priority Health Alcohol and Drug Abuse Treatment Benefit Reminder First Priority Health would like to remind the network that the following covered services are provided only when medically necessary and when the First Priority Health Regional Referral Center (RRC) 1-800-599-2428 is notified by the participating provider or the member before the services are rendered, and the provider coordinates the member’s care.
Alcohol and/or Drug Abuse Covered Services include:
Outpatient - Member is eligible for thirty (30) outpatient full service visits or equivalent partial visits per calendar year for treatment of alcohol and/or drug abuse or dependency. Member is additionally eligible for thirty (30) separate sessions of outpatient visits or partial hospitalization days per calendar year. These additional thirty (30) sessions may be exchanged on a two-for-one basis for up to fifteen (15) inpatient non hospital residential care days, as described in paragraph 3. Treatment for alcohol and/or drug abuse or dependency shall be provided according to an individual treatment plan, subject to a lifetime limit of one hundred twenty (120) visits.
Inpatient Detoxification - Member is eligible for inpatient detoxification benefits in either a participating hospital or an inpatient non hospital residential facility. This inpatient detoxification benefit is subject to a lifetime maximum of four (4) admissions per member. Reimbursement per admission is limited to a maximum of seven (7) days of treatment or an equivalent amount.
Copayment – If applicable, the member is responsible for the appropriate copayment in the amount shown for inpatient alcohol and/or drug abuse treatment on the member payment schedule attached to his/her contract.
Deductibles and Coinsurance – If applicable, the member is responsible for the appropriate deductibles and coinsurance shown for inpatient alcohol and/or drug abuse treatment on the member payment schedule attached to his/her contract. Inpatient non-hospital residential care for alcohol and/or drug treatment:
First course of treatment - $0.
Second and subsequent courses of treatment - 50% of the cost of service.
Note: The maximum annual copayments for all services made by or on behalf of a member during the year of his/her contract shall not exceed fi fty (50) percent of the total annual premium that the member would be required to pay if no copayments were charged for services pursuant to their contract. Because this figure is subject to change, contact First Priority Health’s Provider Services Unit for verification. The member must demonstrate that copayments in excess of such amount have been paid during the year of their contract. (policy update 0803004)