Plan Year Deductible Out-of-Pocket Maximum Lifetime Maximum EHP Network Provider Out of Network Provider Suburban Hospital (facility charges only) Individual $400 $750 $0 Family $800 $1500 $0 Individual $2500 $2500 Included in EHP Network Provider Medical maximum Family $5000 $5000 Included in EHP Network Provider Medical maximum Unlimited Acupuncture Allergy Tests & Procedures for anesthesia, pain control, and therapeutic purposes 80% of allowed amount; deductible applies (15 visit annual maximum for all networks combined) 70% of (15 visit annual maximum for all networks combined) Allergy tests 100% of allowed amount; deductible 70% of Desensitization materials and serum 100% of allowed amount; deductible 70% of Ambulance Transportation Medically necessary transport 80% of allowed amount; deductible applies 70% of Biofeedback Chemo & Radiation Therapy Chiropractic Care Biofeedback Physician visit 80% of allowed amount; deductible applies 70% of 100% (facility charge only) Materials and treatment 80% of allowed amount; deductible applies 70% of 100% (facility charge only) Chiropractor restricted to initial exam, x-rays, and spinal manipulations Chiropractor with PT privileges (physical therapy services) 80% of allowed amout; deductible applies (15 visit annual maximum for all networks combined) 70% of (15 visit annual maximum for all networks combined) Refer to Therapy section Refer to Therapy section Refer to Therapy section Dialysis 80% of allowed amount; deductible applies 70% of Durable Medical Equipment Breast pumps (standard) and related supplies 100% of allowed amount; deductible 70% of Contraceptive devices 100% of allowed amount; deductible 70% of Custom DME, including custom wheelchairs Custom-molded orthotics Insulin pumps, Continuous Glucose Monitor and related supplies 80% of allowed amount; deductible applies 70% of required; $250 lifetime 70% of (preauthorization required; $250 lifetime 80% of allowed amount; deductible applies 70% of Hearing aids Not Covered Not Covered Non-custom medical equipment and supplies Prosthetic devices 80% of allowed amount; deductible applies 70% of E00070 Page 1 of 5
Emergency Services Home Health Services Emergency care (facility Emergency care (professional Home infusion therapy $75 co-pay, then 90% of allowed amount; deductible (co-pay if admitted) $75 co-pay, then 90% of R&C; deductible (co-pay if admitted) $75 co-pay, then 90% of allowed amount (co-pay if admitted) 90% of allowed amount; deductible 90% of R&C; deductible 90% of allowed amount $20 co-pay; deductible (120 visit annual maximum; pre-authorization required) 70% of (120 visit annual maximum; pre-authorization required) 70% of Hospice Care Inpatient and home hospice 80% of allowed amount; deductible applies 70% of Hospital Care Inpatient care including newborn nursery care; NICU (facility Inpatient care (professional 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 $300 co-pay per admission, then 80% of allowed amount; deductible applies (for a service that Suburban does not provide: $100 co-pay per admission, then 100% of allowed amount; deductible ) 80% of allowed amount; deductible applies 70% of 80% of allowed amount 80% of allowed amount; deductible applies (90 day annual 80% of allowed amount; deductible applies (60 day annual $75 co-pay, then 90% of allowed amount; deductible (co-pay if admitted) 70% of (90 day annual 70% of (60 day annual $75 co-pay, then 90% of R&C; deductible (co-pay if admitted) $75 co-pay, then 90% of allowed amount (co-pay if admitted) 90% of allowed amount; deductible 90% of R&C; deductible 90% of allowed amount 80% of allowed amount; deductible applies 70% of 80% of allowed amount Hyperbaric Oxygen Therapy 80% of allowed amount; deductible applies 70% of Immunizations Infusion Therapy Preventive immunizations for communicable diseases 100% of allowed amount; deductible 70% of Travel immunizations 100% of allowed amount; deductible 70% of Home infusion therapy Outpatient infusion therapy 70% of E00070 Page 2 of 5
Injections Laboratory Mental Health & Substance Abuse Services Methodone Treatment Nutritional Counseling Office Visits for Treatment of Illness or Injury Injections 80% of allowed amount; deductible applies 70% of Materials and serum 80% of allowed amount; deductible applies 70% of 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 Medication management Mental health testing and Medically necessary outpatient care 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 ; deductible 100% of allowed amount; deductible ; deductible 100% of allowed amount; deductible 80% of allowed amount; deductible applies (limited to 6 visits per plan year for all networks combined; additional visits must be pre-authorized) 70% of $20 co-pay, then 100% of allowed amount 70% of $20 co-pay, then 100% of allowed amount 70% of $20 co-pay, then 100% of allowed amount 70% of 70% of allowed amount; deductible applies (limited to 6 visits per plan year for all networks combined; additional visits must be pre-authorized) Not available $20 co-pay; deductible 70% of $20 co-pay; deductible 70% of $20 co-pay; deductible 70% of $25 co-pay; deductible 70% of E00070 Page 3 of 5
Preventive Services Preventive exam (PCP, GYN and Well Child care) Diagnostic services for preventive exam Routine preventive screenings: mammogram, colonoscopy, PAP test, etc. Routine hearing exams 100% of allowed amount; deductible (limit one per plan year; birth to age one: 6 visit limit; age one to age two: 2 visit limit; age two to age six: 1 visit per plan year limit) 70% of (limit one per plan year; birth to age one: 6 visit limit; age one to age two: 2 visit limit; age two to age six: 1 visit per plan year limit) 100% of allowed amount; deductible 100% of allowed amount; deductible (mammogram limited to one baseline exam between ages 35 to 39; one per plan year age 40 and up) $20 co-pay; deductible (limit one every 24 months) 70% of (mammogram limited to one baseline exam between ages 35 to 39; one per plan year age 40 and up) 70% of (limit one every 24 months) Private Duty Nursing Private Duty Nursing 80% of allowed amount; deductible applies 70% of Radiology Procedures Reproductive Health Advance imaging including MRI, CT and PET scans All other imaging studies; including X-Ray and Ultrasound Physician office visits (prenatal care only) Infertility treatment $25 co-pay; deductible 70% of $25 co-pay, then 100% of allowed amount; for artificial insemination only, deductible (6 AI attempts lifetime pre-authorization required 70% of R&C for artificial insemination only, deductible applies (6 AI attempts lifetime pre-authorization required Birthing centers (facility 100% of allowed amount; deductible 70% of Birthing centers (professional Inpatient maternity care and delivery; newborn nursery care; NICU (facility Inpatient maternity care and delivery; newborn nursery care; NICU (professional 100% of allowed amount; deductible 70% of ; deductible 100% of allowed amount; deductible 70% of Interruption of pregnancy Female sterilization (professional services for surgery, anesthesia and related pathology) Male sterilization (professional services for surgery, anesthesia and related pathology) 100% of allowed amount; deductible 100% of allowed amount; deductible E00070 Page 4 of 5
Surgical Procedures Therapy Urgent Care Center Surgical treatment for morbid obesity Primary care office surgical Specialist care office surgical Outpatient surgery (including freestanding surgical centers) (facility Outpatient surgery (including freestanding surgical centers) (professional Covered at Johns Hopkins Bayview Medical Center and Sibley Memorial Hospital only. $300 co-pay per admission, then 80% of allowed amount; deductible applies, preauthorization required (Services paid as stated regardless of no availability at Suburban Hospital) Not Covered $20 co-pay; deductible 70% of $25 co-pay; deductible 70% of Inpatient surgery (facility Inpatient surgery (professional Habilitative services for children under the age of 19 Physical therapy/occupational therapy medically necessary services Speech therapy (nondevelopmental medically necessary services) required) required for visits > 12) 70% of (preauthorization required) 70% of (preauthorization required for visits > 12) 100% of allowed amount (pre-authorization required for visits > 12) Pulmonary rehabilitation Cardiac rehabilitation Vision therapy Not Covered Not Covered Not Covered Physician visit $20 co-pay; deductible 70% of Diagnostic services and treatment 100% of allowed amount 70% of E00070 Page 5 of 5