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53 Mental Health Inpatient (preauthorization required) $100 copay per admission; Limited to 30 days per year $5 copay per admission; Limited to 30 days per year Substance Abuse Inpatient (preauthorization required) $100 copay per admission; Limited to two 5-day detox stays per lifetime; plus one 28-day lifetime stay $5 copay per admission; Limited to two 5-day detox stays per lifetime; plus one 28-day lifetime stay Mental Health/Substance Abuse Outpatient (preauthorization required) $20 copay per session; Limited to 52 sessions mental health and substance abuse combined $5 copay per session; Limited to 52 sessions mental health and substance abuse combined Dental Services No copay for routine preventive oral exam, x-rays, cleaning and fluoride application $15 copay per visit No copay for routine preventive oral exam, x-rays, cleaning and fluoride application $5 copay per visit Vision Care Preventive services (annual exam and glaucoma testing) – No copay $ 15 copay - prescription lenses and frames or contact lenses Preventive services (annual exam and glaucoma testing) – No copay $5 copay - prescription lenses and frames or contact lenses Annual Out-of-Pocket Maximums 5% of family income 5% of family income