exclusions. 
MENTAL HEALTH SERVICES 
Inpatient 
Your plan covers up to 190 days 
in alifetime for inpatient mental 
health care in apsychiatric 
hospital $500 copay per day for days 1-4 
$0 copay per day for days 5-90 $500 copay per day for days 1-4 
$0 copay per day for days 5-90 You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs 
may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please