Plan Year Deductible Out-of-Pocket Maximum Lifetime Maximum EHP Network Provider Out of Network Provider Hopkins Preferred Network Provider Individual $100 $750 $0 Family $200 $1500 $0 Individual $2000 $3500 Family $4000 $7000 Unlimited Included in EHP Network Provider Medical maximum Included in EHP Network Provider Medical maximum Acupuncture Allergy Tests & Procedures for anesthesia, pain control, and therapeutic purposes $30 co-pay for office visit, then 100% of allowed amount; deductible applies ($1500 annual maximum for all networks combined) 70% of R&C; deductible applies ($1500 annual maximum for $30 co-pay for office visit, then 100% of allowed amount; ($1500 annual maximum for Allergy tests Desensitization materials and serum Ambulance Transportation Medically necessary transport 100% of allowed amount; deductible waived 100% of R&C; deductible waived 100% of allowed amount Biofeedback Biofeedback Not Covered Not Covered Not Covered Chemo & Radiation Therapy Chiropractic Care Dialysis Durable Medical Equipment Physician visit $30 co-pay of allowed amount; deductible applies 70% of R&C; deductible applies $30 co-pay of allowed amount Materials and treatment Chiropractor restricted to initial exam, x-rays, and spinal manipulations Chiropractor with PT privileges (physical therapy services) Breast pumps (standard) and related supplies $15 co-pay for office visit, then 100% of allowed amount; deductible applies ($1500 annual maximum for all networks combined) 70% of R&C; deductible applies ($1500 annual maximum for $15 co-pay for office visit, then 100% of allowed amount; ($1500 annual maximum for Refer to Therapy section Refer to Therapy section Refer to Therapy section 90% of allowed amount; deductible applies; 100% at Davita Dialysis Centers; deductible waived (pre-authorization 70% of R&C; deductible applies (pre-authorization 100% of allowed amount; deductible waived 70% of R&C; deductible applies (pre-authorization 100% of allowed amount; includes Davita Dialysis Centers (pre-authorization 100% of allowed amount for Johns Hopkins Home Care Group/Pharmaquip Contraceptive devices Custom DME, including custom wheelchairs Custom-molded orthotics Insulin pumps, Continuous Glucose Monitor and related supplies Hearing aids Non-custom medical equipment and supplies Prosthetic devices 100% of allowed amount; deductible waived (pre-authorization 70% of R&C; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization 100% of allowed amount; (pre-authorization ; 100% of allowed amount; deductible waived (for dependent children under age 26; pre-authorization required; replacement aids once every 36 months 70% of R&C; deductible applies (for dependent children under age 26; pre-authorization required; replacement aids once every 36 months 90% of allowed amount; deductible applies 70% of R&C; deductible applies 100% of allowed amount; deductible waived (pre-authorization 70% of R&C; deductible applies (pre-authorization 100% of allowed amount; (for dependent children under age 26; pre-authorization required; replacement aids once every 36 months 100% of allowed amount for Johns Hopkins Home Care Group/Pharmaquip 100% of allowed amount; (pre-authorization E00006, E00007, E00161 Page 1 of 6
Emergency Services Home Health Services Hospice Care Hospital Care Hyperbaric Oxygen Therapy Immunizations Infusion Therapy Emergency care Emergency care (professional Home infusion therapy Inpatient and home hospice Inpatient care including newborn nursery care; NICU $150 co-pay, then 100% of allowed amount; deductible waived (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage $150 co-pay, then 100% of R&C; deductible waived (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage $150 co-pay, then 100% of allowed amount (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage 100% of allowed amount; deductible waived 100% of R&C; deductible waived 100% of allowed amount 100% of allowed amount; deductible waived (40 visits per year maximum for all networks combined; pre-authorization 100% of allowed amount; deductible waived (pre-authorization $150 co-pay per admission, then 90% of allowed amount; deductible waived (semi-private, unless private room is medically necessary; pre-authorization 70% of R&C; deductible applies (40 visits per year maximum for all networks combined; pre-authorization 70% of R&C; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization applies (semi-private, unless private room is medically necessary; pre-authorization 100% of allowed amount; (40 visits per year maximum for all networks combined; preauthorization 100% of allowed amount for services through Johns Hopkins Home Care Group (preauthorization allowed amount (semi-private, unless private room is medically necessary; pre-authorization Inpatient care Skilled nursing/rehabilitation facility Short-term acute rehabilitation Observation care Observation care (professional Outpatient surgery & ambulatory surgical center Outpatient surgery & ambulatory surgical center Preventive immunizations for communicable diseases First 30 days covered at 100% of allowed amount, remaining days at 90% of allowed amount; deductible applies (120 days per year maximum all networks combined for medically necessary services; pre-authorization First 30 days covered at 100% of allowed amount, remaining days at 90% of allowed amount; deductible applies (120 days per year maximum all networks combined for medically necessary services; pre-authorization $150 co-pay, then 100% of allowed amount; deductible waived (if admitted, observation co-pay waived; see Inpatient Facility Care for coverage) 70% of R&C; deductible applies (120 days per year maximum all networks combined for medically necessary services; preauthorization 70% of R&C; deductible applies (120 days per year maximum all networks combined for medically necessary services; preauthorization $150 co-pay, then 100% of allowed amount; deductible waived (if admitted, observation co-pay waived; see Inpatient Facility Care for coverage) 100% of allowed amount (120 days per year maximum all networks combined for medically necessary services; pre-authorization 100% of allowed amount (120 days per year maximum all networks combined for medically necessary services; pre-authorization $150 co-pay, then 100% of allowed amount (if admitted, observation co-pay waived; see Inpatient Facility Care for coverage) 100% of allowed amount; deductible waived 100% of allowed amount; deductible waived 100% of allowed amount 90% of allowed amount; deductible applies (includes 90% of allowed amount; deductible applies (includes outpatient testing prior to outpatient surgery) 70% of R&C; deductible applies (includes freestanding surgical centers) 70% of R&C; deductible applies (includes outpatient testing prior to outpatient surgery) 70% of R&C; deductible applies (pre-authorization 100% of allowed amount (includes 100% of allowed amount (includes outpatient testing prior to outpatient surgery) Travel immunizations Home infusion therapy 70% of R&C; deductible applies (pre-authorization 100% of allowed amount for services through Johns Hopkins Home Care Group (preauthorization Outpatient infusion therapy E00006, E00007, E00161 Page 2 of 6
Injections Laboratory Mental Health & Substance Abuse Services Methadone Treatment Nutritional Counseling Injections Materials and serum Laboratory tests including pathology Outpatient mental health care Outpatient mental health care Inpatient mental health care Inpatient mental health care Outpatient substance abuse care Outpatient substance abuse care Inpatient substance abuse care Inpatient substance abuse care Intensive outpatient program Partial hospital facility services Medication management Mental health testing and procedures Medically necessary outpatient care $10 co-pay, then 100% of allowed amount; deductible waived 70% of R&C; deductible applies $10 co-pay, then 100% of allowed amount $10 co-pay, then 100% of allowed amount; deductible waived 70% of R&C; deductible applies $10 co-pay, then 100% of allowed amount allowed amount; deductible waived (pre-authorization applies (pre-authorization allowed amount (pre-authorization $10 co-pay, then 100% of allowed amount; deductible waived 70% of R&C, deductible applies $10 co-pay, then 100% of allowed amount $10 co-pay, then 100% of allowed amount; deductible waived 70% of R&C, deductible applies $10 co-pay, then 100% of allowed amount allowed amount; deductible waived (pre-authorization applies (pre-authorization allowed amount (pre-authorization $10 co-pay per day, then 100% of allowed amount; deductible waived (pre-authorization $10 co-pay per day, then 100% of allowed amount; deductible waived (pre-authorization $10 co-pay per day, then 100% of allowed amount; deductible waived $10 co-pay, then 100% of allowed amount; deductible waived (pre-authorization $10 co-pay; then 100% allowed amount; deductible waived (pre-authorization $30 co-pay for office visit; deductible applies (limited to 6 visits per plan year for all networks combined; additional visits must be pre-authorized) 70% of R&C; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization 70% of R&C; deductible applies 70% of R&C; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization 70% of R&C, deductible applies (limited to 6 visits per plan year for all networks combined; additional visits must be preauthorized) $10 co-pay per day, then 100% of allowed amount (pre-authorization $10 co-pay per day, then 100% of allowed amount (pre-authorization $10 co-pay per day, then 100% of allowed amount $10 co-pay, then 100% of allowed amount (pre-authorization $10 co-pay; then 100% allowed amount; (preauthorization $15 co-pay, then 100% of allowed amount (limited to 6 visits per plan year for all networks combined; additional visits must be pre-authorized) E00006, E00007, E00161 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. Designated Medical PCP: $10 co-pay; deductible waived; Non-Designated Medical PCP: $20 co-pay; deductible waived Designated Medical PCP: $10 co-pay; deductible waived; Non-Designated Medical PCP: $20 co-pay; deductible waived 70% of R&C; deductible applies 70% of R&C; deductible applies Designated Medical PCP: $10 co-pay; Non- Designated Medical PCP: $20 co-pay Designated Medical PCP: $10 co-pay; Non- Designated Medical PCP: $20 co-pay GYN PCPs: $10 co-pay; deductible waived 70% of R&C; deductible applies GYN PCPs: $10 co-pay $30 co-pay for office visit; eductible applies then 100% of allowed amount; deductible applies 70% of R&C; deductible applies $30 co-pay, then 100% of allowed amount 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% of allowed amount; deductible applies 70% of R&C; deductible applies $50 co-pay, then 100% of allowed amount 90% of allowed amount; deductible applies 70% of R&C; deductible applies $10 co-pay, then 100% of allowed amount E00006, E00007, E00161 Page 4 of 6
Reproductive Health Surgical Procedures Physician office visits (prenatal care only) Infertility treatment Covered at Johns Hopkins Fertility Center only Covered at Johns Hopkins Fertility Center only 100% of allowed amount after separate $1000 lifetime deductible (deductible applies to services attached to the IVF authorization for treatment; deductible does not apply to testing; 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, all services provided at Johns Hopkins Fertility Center only; member must be enrolled in the EHP Plan for one year before beginning infertility treatment) Birthing centers 100% of allowed amount; deductible applies 70% of R&C; deductible applies Not Available Birthing centers (professional Inpatient maternity care and delivery; newborn nursery care; NICU Inpatient maternity care and delivery; newborn nursery care; NICU $150 co-pay per admission, then 90% of allowed amount; deductible waived(pre-authorization applies (pre-authorization allowed amount (pre-authorization Interruption of pregnancy 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 Outpatient surgery (including Inpatient surgery Inpatient surgery (professional Covered at Johns Hopkins Bayview Medical Center & Sibley Memorial Hospital only Covered at Johns Hopkins Bayview Medical Center & Sibley Memorial Hospital only Covered at Johns Hopkins Bayview Medical Center & Sibley Memorial Hospital only; $150 Inpatient facility co-pay, then 100% of allowed amount for Professional fees (preauthorization $150 co-pay per admission, then 90% of allowed amount; deductible waived (pre-authorization $300 co-pay per admission, then 90% of allowed amount; deductible applies (pre-authorization allowed amount; (pre-authorization E00006, E00007, E00161 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) Pulmonary rehabilitation Cardiac rehabilitation 90% of allowed amount; deductible applies (60 visits per year maximum for all networks combined; PT/OT pre-authorization required for visits 13-60) 90% of allowed amount; deductible applies (30 visits per year maximum for all networks combined; pre-authorization 90% of allowed amount, deductible applies (pre-authorization 90% of allowed amount, deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization 70% of R&C; deductible applies (60 visits per year maximum for all networks combined; PT/OT pre-authorization required for visits 13-60) 70% of R&C; deductible applies (30 visits per year maximum for all networks combined; pre-authorization 70% of R&C; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization $10 co-pay, then 100% of allowed amount (pre-authorization $10 co-pay, then 100% of allowed amount (60 visits per year maximum for all networks combined; PT/OT pre-authorization required for visits 13-60) $10 co-pay, then 100% of allowed amount (30 visits per year maximum for all networks combined; pre-authorization Vision therapy Not Covered Not Covered Not Covered Physician visit $25 co-pay; deductible waived 70% of R&C; deductible applies $25 co-pay Diagnostic services and treatment E00006, E00007, E00161 Page 6 of 6