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<br />or Program when authorized in <br />advance by Health Plan. <br /> <br />3. <br /> <br />Maternity Services <br /> <br />Maternity related medical, hospital and other <br />covered Health Services de~med Medically Neces- <br />sary by the Participating Physician shall be <br />provided as any other illness and/or InJury. <br /> <br />4. <br /> <br />Mental Health <br /> <br />The following Mental Health Services are covered <br />when authorized in advance by Health Plan and <br />its Psychiatric Primary Provider: <br /> <br />a. <br /> <br />Outpatient'mental health evaluations, <br />crisis intervention, diagnosis, <br />therapeutic services, and referral are <br />provided only by Health Plan's Psychia- <br />tric Primary Provider. <br /> <br />b. <br /> <br />Inpatient services and supplies on a <br />semi-private accommodation basis for <br />that period of time deemed Medically <br />Necessary in a Participating Hospital, <br />or other Approved Health Care Facility <br />or Program when provided by a Psychiatric <br />Primary Provider or when provided by a <br />physician under the authorization of the <br />Psychiatric Primary Provider. <br /> <br />c. <br /> <br />Services of a Psychiatric Primary <br />Provider or a physician authorized by the <br />Psychiatric Primary Provider while Covered <br />Person is confined a bed patient in a <br />Participating Hospital or other Approved <br />Health Care Facility or Program. <br /> <br />d. <br /> <br />Services provided in an approved psychia- <br />tric day treatment facility under the di- <br />rection of a Psychiatric Primary Provider. <br />Benefits shall count as one-half of one day <br />inpatient Mental Health Services. A <br />combination of benefits for these services <br />and inpatient services shall not exceed <br />the maximum benefit as stated for inpatient <br />Mental Health Services. <br /> <br />5. <br /> <br />Medical and Hospital Services Related to <br />Reconstructive Surgery When Authorized by <br />Health Plan <br /> <br />Reconstructive surgery and all other required <br /> <br />SB-A2 <br /> <br />-5- <br /> <br />Same as E.1 and E.2 <br />of the Schedule <br />of Benefits. <br /> <br />$15 per visit, not <br />to exceed 20 visits <br />per Calendar Year, a <br />visit not to exceed <br />one hour in dura- <br />tion. <br /> <br />20% of Eligible <br />Expenses, not to <br />exceed 30 days per <br />Calendar Year. <br /> <br />NONE. Physician <br />visits are not to <br />exceed the same <br />30 day period as <br />specified in <br />4. b. <br /> <br />20% of Eligible <br />Expenses, not to <br />exceed 60 days per <br />Calendar Year. <br /> <br />NONE <br />