Noblesville Schools Medical Plan 47 Section 1: Covered Health Care Services • Physician services for radiologists, anesthesiologists, pathologists and Emergency room Physicians. (Benefits for other Physician services are described under Physician Fees for Surgical and Medical Services.) Lab, X-Ray and Diagnostic - Outpatient Services for Sickness and Injury-related diagnostic purposes, received on an outpatient basis at a Hospital or Alternate Facility or in a Physician's office include: • Lab and radiology/X-ray. • Mammography. Benefits include: • The facility charge and the charge for supplies and equipment. • Physician services for radiologists, anesthesiologists and pathologists. (Benefits for other Physician services are described under Physician Fees for Surgical and Medical Services.) • Genetic Testing ordered by a Physician which results in available medical treatment options following Genetic Counseling. • Presumptive Drug Tests and Definitive Drug Tests. Lab, X-ray and diagnostic services for preventive care are described under Preventive Care Services. CT scans, PET scans, MRI, MRA, nuclear medicine and major diagnostic services are described under Major Diagnostic and Imaging - Outpatient. Major Diagnostic and Imaging - Outpatient Services for CT scans, PET scans, MRI, MRA, nuclear medicine and major diagnostic services received on an outpatient basis at a Hospital or Alternate Facility or in a Physician's office. Benefits include: • The facility charge and the charge for supplies and equipment. • Physician services for radiologists, anesthesiologists and pathologists. (Benefits for other Physician services are described under Physician Fees for Surgical and Medical Services.) Mental Health Care and Substance-Related and Addictive Disorders Services The Mental Health/Substance-Related and Addictive Disorders Delegate (the Delegate) administers Benefits for Mental Health and Substance-Related and Addictive Disorders Services. If you need assistance with coordination of care, locating a provider, and confirmation that services you plan to receive are Covered Health Care Services, you can contact the Delegate at the telephone number on your ID card. Mental Health Care and Substance-Related and Addictive Disorders Services include those received on an inpatient or outpatient basis in a Hospital, an Alternate Facility or in a provider's office. All services must be provided by or under the direction of a behavioral health provider who is properly licensed and qualified by law and acting within the scope of their licensure. Benefits include the following levels of care: • Inpatient treatment. • Residential Treatment. • Partial Hospitalization/Day Treatment/High Intensity Outpatient.