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<br />DRUG DEPENDENCY RIDER <br />FOR USE ONLY WITH CENTRAL TEXAS HEALTH PLAN <br />MASTER CONTRACTS AND SUBSCRIBER CERTIFICATES <br /> <br />In consideration of timely payment of premium, it is agreed that the <br />benefits of this Rider together with the terms and conditions hereof shall <br />be added to the Benefits, Terms, and Conditions of the Central Texas Health <br />Plan Group Master Contract/Certificate in conJunction with this Rider as <br />issued. <br /> <br />PART I - DEFINITIONS <br /> <br />Benefits for substance abuse/chemical dependency <br />Ridet' at'e subject tl) the provisions tCI <br />Contract/Certificate to which this Rider is a part. <br /> <br />provided through this <br />the Group Master <br /> <br />PART II - BENEFITS <br /> <br />FOt, the pUt'poJse .,f this Rider, benefits fclr the treatment oJf substance <br />abuse/chemical dependeYH:::y wi 11 only be pt'ovided when authorized in advance <br />by the Heal th Plan and its Psych iatt'ic Pt'imat'y Pt'ovidet'. Necessary <br />treatment includes but is not limited to outpatient or inpatient care in a <br />hospital or other substance abuse/chemical dependency treatment center: <br /> <br />Necessary treatment includes but is not limited to the following: <br /> <br />- Medical evaluations. <br />- Psychiatric evaluations when recommended by a participating CTHP <br />Physician performing the medical evaluation. <br />- Room and board (inpatient only). <br />- Psychotherapy (individual and group). <br />- Counseling (individual and group). <br />- Dt'ug thet'apy <leading to t'ehabilitati')n,. riot maintenance). <br />- Behavior therapy (inpatient only). <br />- Recreation therapy (inpatient only). <br />- Family Therapy (individual and group on an outpatient basis only). <br />- Drugs and necessary supplies dispensed in covered settings when other <br />c;:¡vered services are t'erldet'ed. <br /> <br />A. <br /> <br />Bertefi t Dut,.~t iQn & Member C¡jst <br /> <br />Durat i':¡("1 ojf berlefi ts shall be 1 imi ted as speci fied below and subject <br />to the copayments described. Maximum covered services per Contract <br />Year shall be $5,000. Services exceeding the $5,000 maximum shall be <br />the mem~r's sole resPQnsibility. <br /> <br />Inpatient Benefit <br /> <br />30 days of care in each contract year. <br />Maximum of two such benefit periods per <br />member lifetime. Member pays 2Ø~ of <br />covered services. <br /> <br />Outpat ient Cat'e <br /> <br />30 visits for individual sessions; 60 <br />group sessions per Contract Year. <br />Member pays $15 per visit. <br /> <br />GMR-7.01 (6/86) <br />