Page 31

SERVICE SCOPE OF BENEFIT (ANNUAL) Including but not limited to: described in the Managed Care Pharmacy Benefit Plan Protocols. Non-Prescription Drugs Covered when prescribed by a Health Plan physician/provider/APP. Limited to non-prescription drugs, as described in the Medicaid Managed Care Pharmacy Benefit Plan Protocols. Includes nicotine cessation supplies ordered by an MCO physician or APP. Includes medically necessary nutritional supplements ordered by an MCO physician or APP. Laboratory Services Covered when ordered by a Health Plan physician/provider including urine drug screens. Radiology Services Covered when ordered by a Health Plan physician/provider. Diagnostic Services Covered when ordered by a Health Plan physician/provider. Mental Health and Substance Use – Outpatient & Inpatient Covered as needed for all members, including residential substance use treatment for youth. Covered services include a full continuum of mental health and substance use disorder treatment, including but not limited to, community-based narcotic treatment, methadone, and community detox. Covered residential treatment includes therapeutic services but does not include room and board, except in a facility accredited by the Joint Commission on Accreditation of Healthcare Organizations ("JCAHO"). Also includes, DCYF ordered administratively necessary days, or hospital-based detox, MH/SUD residential treatment (including minimum six (6) month SSTAR birth residential services), Mental Health Psychiatric Rehabilitative Residence (MHPRR), psychiatric rehabilitation day programs, Community Psychiatric Supportive Treatment (CPST),Crisis Intervention for individuals with severe and persistent mental illness (SPMI) enrolled in the Community Support Program (CSP), Opioid Treatment Program Health Homes (OTP),