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 Family $5000 $5000 Unlimited Included in EHP Network Provider Medical maximum Included in EHP Network Provider Medical maximum Acupuncture Allergy Tests & Procedures Medically necessary services for anesthesia, pain control, and therapeutic purposes 80% of ; deductible (15 visit annual maximum for all networks combined) 70% of R&C; deductible (15 visit annual maximum for all networks combined) Allergy tests 100% of ; deductible 70% of R&C; deductible Desensitization materials and serum 100% of ; deductible 70% of R&C; deductible Ambulance Transportation Medically necessary transport 80% of ; deductible 70% of R&C; deductible Biofeedback Chemo & Radiation Therapy Chiropractic Care Biofeedback Physician visit 80% of ; deductible 70% of R&C; deductible 100% (facility charge only) Materials and treatment 80% of ; deductible 70% of R&C; deductible 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 (15 visit annual maximum for all networks combined) 70% of R&C; deductible (15 visit annual maximum for all networks combined) Refer to Therapy section Refer to Therapy section Refer to Therapy section Dialysis Medically necessary services 80% of ; deductible 70% of R&C; deductible Durable Medical Equipment Breast pumps (standard) and related supplies 100% of ; deductible 70% of R&C; deductible Contraceptive devices 100% of ; deductible 70% of R&C; deductible Custom DME, including custom wheelchairs Custom-molded orthotics Insulin pumps, Continuous Glucose Monitor and related supplies 80% of ; deductible 70% of R&C; deductible 80% of ; deductible (preauthorization required; $250 lifetime maximum) 70% of R&C; deductible (pre-authorization required; $250 lifetime maximum) 80% of ; deductible 70% of R&C; deductible Hearing aids Not Covered Not Covered Non-custom medical equipment and supplies Prosthetic devices 80% of ; deductible 70% of R&C; deductible E00070 Page 1 of 6
Emergency Services Home Health Services Emergency care Emergency care (professional Medically necessary services Home infusion therapy $75 co-pay, then 90% of ; deductible (co-pay if admitted) $75 co-pay, then 90% of R&C; deductible (co-pay if admitted) $75 co-pay, then 90% of (copay if admitted) 90% of ; deductible 90% of R&C; deductible 90% of $20 co-pay; deductible (120 visit annual maximum; pre-authorization required) 70% of R&C; deductible (120 visit annual maximum; pre-authorization required) 70% of R&C; deductible Hospice Care Inpatient and home hospice 80% of ; deductible 70% of R&C; deductible Hospital Care Inpatient care including newborn nursery care; NICU $300 co-pay per admission, then 80% of ; deductible (for a service that Suburban does not provide: allowed amount; deductible ) Inpatient care 80% of ; deductible 70% of R&C; deductible 80% of Skilled nursing/rehabilitation facility Short-term acute rehabilitation Observation care Observation care (professional Outpatient surgery & ambulatory surgical center Outpatient surgery & ambulatory surgical center (professional 80% of ; deductible (90 day annual maximum) 80% of ; deductible (60 day annual maximum) $75 co-pay, then 90% of ; deductible (co-pay if admitted) 70% of R&C; deductible (90 day annual maximum) 70% of R&C; deductible (60 day annual maximum) $75 co-pay, then 90% of R&C; deductible (co-pay if admitted) $75 co-pay, then 90% of (copay if admitted) 90% of ; deductible 90% of R&C; deductible 90% of 80% of ; deductible 70% of R&C; deductible 80% of Hyperbaric Oxygen Therapy Medically necessary services 80% of ; deductible 70% of R&C; deductible Immunizations Infusion Therapy Preventive immunizations for communicable diseases 100% of ; deductible 70% of R&C; deductible Travel immunizations 100% of ; deductible 70% of R&C; deductible Home infusion therapy Outpatient infusion therapy 70% of R&C; deductible E00070 Page 2 of 6
Injections Laboratory Mental Health & Substance Abuse Services Methadone Treatment Nutritional Counseling Injections 80% of ; deductible 70% of R&C; deductible Materials and serum 80% of ; deductible 70% of R&C; deductible 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 Medically necessary services ; deductible 100% of ; deductible ; deductible 100% of ; deductible 70% of R&C; deductible $20 co-pay, then 100% of 70% of R&C; deductible $20 co-pay, then 100% of 70% of R&C; deductible $20 co-pay, then 100% of 70% of R&C; deductible 80% of ; deductible (limited to 6 visits 70% of ; deductible (limited to 6 visits per plan year for all networks combined; additional visits must per plan year for all networks combined; additional visits must be pre-authorized) be pre-authorized) Not available E00070 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. $20 co-pay; deductible 70% of R&C; deductible $20 co-pay; deductible 70% of R&C; deductible $20 co-pay; deductible 70% of R&C; deductible $25 co-pay; deductible 70% of R&C; deductible 100% of ; 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 R&C; 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) 100% of ; deductible 100% of ; deductible (mammogram limited to one baseline exam between ages 35 to 39; one per plan year age 40 and up) 70% of R&C; deductible (mammogram limited to one baseline exam between ages 35 to 39; one per plan year age 40 and up) Routine hearing exams $20 co-pay; deductible (limit one every 24 months) 70% of R&C; deductible (limit one every 24 months) Private Duty Nursing Private Duty Nursing 80% of ; deductible 70% of R&C; deductible Radiology Procedures Advance imaging including MRI, CT and PET scans All other imaging studies; including X-Ray and Ultrasound E00070 Page 4 of 6
Reproductive Health Surgical Procedures Physician office visits (prenatal care only) Infertility treatment $25 co-pay; deductible 70% of R&C; deductible $25 co-pay, then 100% of ; for artificial insemination only, deductible (6 AI attempts lifetime maximum) pre-authorization required 70% of R&C for artificial insemination only, deductible (6 AI attempts lifetime maximum) pre-authorization required Birthing centers 100% of ; deductible 70% of R&C; deductible Birthing centers (professional Inpatient maternity care and delivery; newborn nursery care; NICU Inpatient maternity care and delivery; newborn nursery care; NICU 100% of ; deductible 70% of R&C; deductible ; deductible 100% of ; deductible 70% of R&C; deductible 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 freestanding surgical centers) Outpatient surgery (including freestanding surgical centers) 100% of ; deductible 100% of ; deductible Covered at Johns Hopkins Bayview Medical Center and Sibley Memorial Hospital only. $300 co-pay per admission, then 80% of ; deductible, preauthorization required (Services paid as stated regardless of no availability at Suburban Hospital) Not Covered $20 co-pay; deductible 70% of R&C; deductible $25 co-pay; deductible 70% of R&C; deductible Inpatient surgery Inpatient surgery (professional E00070 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) 80% of ; deductible (preauthorization required) 80% of ; deductible (preauthorization required for visits > 12) 70% of R&C; deductible (pre-authorization required) 70% of R&C; deductible (pre-authorization required for visits > 12) 100% of (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 R&C; deductible Diagnostic services and treatment 100% of 70% of R&C; deductible E00070 Page 6 of 6