Plan Year Deductible Out-of-Pocket Maximum Lifetime Maximum Individual Family Individual Family Hopkins Preferred Network Provider EHP Network Provider Out of Network Provider $150 (under $50K) / $200 ($50K to $111,999K) / $300 $300 (under $50K) / $400 ($50K to $111,999K) / $600 $1500 (under $50K) / $2000 ($50K to $111,999K) / $3000 $3000 (under $50K) / $4000 ($50K to $111,999K) / $6000 $150 (under $50K) / $200 ($50K to $111,999K) / $300 $300 (under $50K) / $400 ($50K to $111,999K) / $600 $1500 (under $50K) / $2000 ($50K to $111,999K) / $3000 $3000 (under $50K) / $4000 ($50K to $111,999K) / $6000 Unlimited $750 $1500 $3500 $7000 Acupuncture Allergy Tests & Procedures Medically necessary services for anesthesia, pain control, and therapeutic purposes 90%, deductible applies (20 visit annual maximum for all 80%, deductible applies (20 visit annual maximum for all (20 visit annual maximum for all networks combined) Allergy tests 90%, deductible applies 80%, deductible applies Desensitization materials and serum 90%, deductible applies 80%, deductible applies Ambulance Transportation Medically necessary transport 100%, deductible applies 100%, deductible applies 100% of allowed benefit; deductible applies Biofeedback Biofeedback 90%, deductible applies 80%, deductible applies Chemo & Radiation Therapy Chiropractic Care Dialysis Durable Medical Equipment Physician visit 90%, deductible applies 80%, deductible applies Materials and treatment 90%, deductible applies 80%, deductible applies Chiropractor restricted to initial exam, x-rays, and spinal manipulations Chiropractor with PT privileges (physical therapy services) Medically necessary services Breast pumps (standard) and related supplies 90%, deductible applies (20 visit annual maximum for all 80%, deductible applies (20 visit annual maximum for all (20 visit annual maximum for all networks combined) Refer to Therapy Section Refer to Therapy Section Refer to Therapy Section 90% at Fresenius/Davita Dialysis Centers; deductible applies 100% for Johns Hopkins Home Care Group/Pharmaquip; deductible waived 80%, deductible applies Contraceptive devices Custom DME, including custom wheelchairs 90%, deductible applies 90%, deductible applies Custom-molded orthotics 90%, deductible applies 80%, deductible applies Insulin pumps, Continuous Glucose Monitor and related supplies Hearing aids Non-custom medical equipment and supplies 90%, deductible applies 90%, deductible applies 90%, deductible applies (Covered only for dependent children under age 26; up to $1,400 per aid; preauthorization required; replacement aids once every 36 months all 90% for Johns Hopkins Home Care Group/Pharmaquip, deductible applies 90%, deductible applies (Covered only for dependent (Covered only for dependent children under children under age 26; up to $1400 per aid; pre-authorization age 26; up to $1,400 per aid; preauthorization required; replacement aids once required; replacement aids once every 36 months all every 36 months all Prosthetic devices 90%, deductible applies 90%, deductible applies 80%, deductible applies E00006 (*003/*004), E00007 (*001/*002), E00161 (*099) Page 1 of 6
Emergency Services Home Health Services Emergency care (facility Emergency care (professional Medically necessary services Home infusion therapy $250 co-pay, then 100%, deductible applies (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage $250 co-pay, then 100%, deductible applies (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage $250 co-pay, then 100% of allowed benefit; deductible applies (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage 100%, deductible applies 100%, deductible applies 100% of allowed benefit; deductible applies 90%, deductible applies (40 visit annual maximum for all 90% for services through Johns Hopkins Home Care Group, deductible applies 90%, deductible applies (40 visit annual maximum for all 80%, deductible applies Hospice Care Inpatient and home hospice 90%, deductible applies 90%, deductible applies Hospital Care Inpatient care including newborn nursery care; NICU (facility (semi-private, unless private room is medically necessary; (semi-private, unless private room is medically necessary; (40 visit annual maximum for all networks combined; allowed benefit; deductible applies (semiprivate, unless private room is medically necessary; Inpatient care (professional 90%, deductible applies 80%, deductible applies Skilled nursing/rehabilitation facility Short-term acute rehabilitation Observation care (facility Observation care (professional Outpatient surgery & ambulatory surgical center (facility Outpatient surgery & ambulatory surgical center (professional 90%, deductible applies (120 day annual maximum all 90%, deductible applies (120 day annual maximum all $250 co-pay, then 100%,; deductible applies (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage First 30 days annually covered at 90%, remaining days at 80%, deductible applies (120 day annual maximum all First 30 days annually covered at 90%, remaining days at 80%, deductible applies (120 day annual maximum all $250 co-pay, then 100%, deductible applies (if admitted, observation co-pay waived; see Inpatient Facility Care for coverage) (120 day annual maximum all networks combined for medically necessary services; (120 day annual maximum all networks combined for medically necessary services; $250 co-pay, then 100% of allowed benefit; deductible applies (if admitted, observation co-pay waived; see Inpatient Facility Care for coverage) 100%, deductible applies 100%, deductible applies 100% of allowed benefit; deductible applies 90%, deductible applies (includes freestanding surgical centers) 80%, deductible applies (includes freestanding surgical centers) 90%, deductible applies 80%, deductible applies Hyperbaric Oxygen Therapy Medically necessary services 90%, deductible applies 80%, deductible applies Immunizations Infusion Therapy Preventive immunizations for communicable diseases Travel immunizations Home infusion therapy 90% for services through Johns Hopkins Home Care Group, deductible applies 80%, deductible applies Outpatient infusion therapy 90%, deductible applies 80%, deductible applies E00006 (*003/*004), E00007 (*001/*002), E00161 (*099) Page 2 of 6
Injections Laboratory Mental Health & Substance Abuse Services Methadone Treatment Nutritional Counseling Injections 90%, deductible applies 80%, deductible applies Materials and serum 90%, deductible applies 80%, deductible applies Laboratory tests including pathology Outpatient mental health care (facility Outpatient mental health care (professional Inpatient mental health care (facility Inpatient mental health care (professional Outpatient substance abuse care (facility Outpatient substance abuse care (professional Inpatient substance abuse care (facility Inpatient substance abuse care (professional Intensive outpatient program Partial hospital facility services 90%, deductible applies 80%, deductible applies $10 co-pay, then $10 co-pay, then $10 co-pay, then $10 co-pay, then 90%, deductible applies 80%, deductible applies $10 co-pay, then $10 co-pay, then $10 co-pay, then $10 co-pay, then 90%, deductible applies 80%, deductible applies Medication management $10 co-pay, then $10 co-pay, then Mental health testing and procedures Medically necessary outpatient care Medically necessary services 90%, deductible applies (limited to 6 visits per plan year for all networks combined; additional visits must be preauthorized) 80%, deductible applies (limited to 6 visits per plan year for all networks combined; additional visits must be preauthorized) (limited to 6 visits per plan year for all networks combined; additional visits must be pre-authorized) E00006 (*003/*004), E00007 (*001/*002), E00161 (*099) Page 3 of 6
Office Visits for Treatment of Illness or Injury Preventive Services Primary care office visit only (Adult) Primary care office visit (Pediatric: age 19 and under) Primary care office visit only (GYN) Specialty care office visit only (Adult & Pediatric) Treatment and diagnostic services in the office Preventive exam (PCP, GYN and Well Child care) Diagnostic services for preventive exam Routine preventive screenings: mammogram, colonoscopy, PAP test, etc. GYN PCPs: $10 co-pay, then GYN PCPs: $10 co-pay, then 90%, deductible applies 80%, deductible applies 90%, deductible applies 80%, deductible applies Routine hearing exams Private Duty Nursing Private Duty Nursing Not Covered Not Covered Not Covered Radiology Procedures Advance imaging including MRI, CT and PET scans All other imaging studies; including X-Ray and Ultrasound 90%, deductible applies 80%, deductible applies 90%, deductible applies 80%, deductible applies E00006 (*003/*004), E00007 (*001/*002), E00161 (*099) Page 4 of 6
Reproductive Health Surgical Procedures Physician office visits (prenatal care only) Infertility treatment 90%, deductible applies 80%, deductible applies Covered at Johns Hopkins Fertility Center only: 90%, deductible applies, plus a separate $1000 lifetime infertility treatment deductible (pre-authorization required for all services and prescriptions; all criteria must be met; $30,000 lifetime maximum combined including prescription drugs, lab work and X-rays, in vitro fertilization attempts limited to a maximum of three per lifetime within the $30,000 lifetime maximum, member must be enrolled in the EHP Plan for one year before beginning infertility treatment) Covered at Johns Hopkins Fertility Center only Covered at Johns Hopkins Fertility Center only Birthing centers (facility Not available 90%, deductible applies Birthing centers (professional Inpatient maternity care and delivery; newborn nursery care; NICU (facility Inpatient maternity care and delivery; newborn nursery care; NICU (professional 90%, deductible applies 80%, deductible applies 90%, deductible applies 80%, deductible applies Interruption of pregnancy 90%, deductible applies 80%, deductible applies Female sterilization (professional services for surgery, anesthesia and related pathology) Male sterilization (professional services for surgery, anesthesia and related pathology) Surgical treatment for morbid obesity Primary care office surgical procedures Specialist care office surgical procedures Outpatient surgery (including freestanding surgical centers) (facility Outpatient surgery (including freestanding surgical centers) (professional Inpatient surgery (facility Inpatient surgery (professional Covered at Johns Hopkins Bayview Medical Center and Sibley Memorial Hospital only; $150 facility co-pay, deductible applies; then 90% for professional fees; deductible applies Covered at Johns Hopkins Bayview Medical Center and Sibley Memorial Hospital only Covered at Johns Hopkins Bayview Medical Center and Sibley Memorial Hospital only 90%, deductible applies 80%, deductible applies 90%, deductible applies 80%, deductible applies 90%, deductible applies 80%, deductible applies 90%, deductible applies 80%, deductible applies 90%, deductible applies 80%, deductible applies E00006 (*003/*004), E00007 (*001/*002), E00161 (*099) Page 5 of 6
Therapy Urgent Care Center Habilitative services for children under the age of 19 Physical therapy/occupational therapy medically necessary services Speech therapy (nondevelopmental medically necessary services) 90%, deductible applies 80%, deductible applies 90%, deductible applies (60 visit annual maximum for all networks combined; PT/OT pre-authorization required for visits 13-60) 90%, deductible applies (30 visit annual maximum for all 80%, deductible applies (60 visit annual maximum for all networks combined; PT/OT pre-authorization required for visits 13-60) 80%, deductible applies (30 visit annual maximum for all Pulmonary rehabilitation 90%, deductible applies 80%, deductible applies Cardiac rehabilitation 90%, deductible applies 80%, deductible applies (60 visit annual maximum for all networks combined; PT/OT pre-authorization required for visits 13-60) (30 visit annual maximum for all networks combined; Vision therapy Not Covered Not Covered Not Covered Physician visit $25 co-pay; then $25 co-pay; then Diagnostic services and treatment E00006 (*003/*004), E00007 (*001/*002), E00161 (*099) Page 6 of 6