Services and Supplies

Navigating healthcare benefits can be confusing. We hope this easy-to-use, interactive site will help you compare the coverage and costs of the plan's three delivery options. You can change your selections at any time.

Alert:

Your browser currently has Javascript disabled. Without it, this interactive benefits viewer will not function. Here are the instructions how to enable JavaScript in your web browser.
 
Step 1



Step 2 Step 3

Calendar Year Deductible

Individual

$100 (Inpatient services only)
$750
$0

Family

$200 (Inpatient services only)
$1,500
$0

Co-Insurance Out of Pocket Maximum - Calendar Year (Includes deductible but not co-pays.) (5)

Individual

$2,000
$3,500
N/A

Family

$4,000
$7,000
N/A

Lifetime Maximum

Individual and Family

unlimited
unlimited
unlimited

Acupuncture

Medically Necessary for anesthesia, pain control, and therapeutic purposes ($1,500 annual maximum)

$40 co-pay
70% of R&C after deductible
$40 co-pay

Allergy Tests And Procedures

Allergy tests

100%
70% of R&C after deductible
100%

Desensitization materials and serum

100%
70% of R&C after deductible
100%

Ambulance Transportation

Medically Necessary transport

100%
100% of R&C
100%

Chemotherapy / Radiation Therapy

Physician Visit

100%
70% of R&C after deductible
100%

Physician Materials

100%
70% of R&C after deductible
100%

Chiropractic Care

Restricted to initial exam, X-rays, & spinal manipulations ($1,500 annual max)

$15 co-pay
70% of R&C after deductible
$15 co-pay

Durable Medical Equipment

Equipment and Medical Supplies

100%
70% of R&C after deductible
100%

Custom Molded Orthotics (pre-certification required )

100%
70% of R&C after deductible
100%

Prosthetic Appliances (pre-certification required )

100%
70% of R&C after deductible
N/A

Medically Necessary hearing aids for dependent children under age 19 (3)

100%
70% of R&C after deductible
N/A

Emergency Services

Emergency Care (facility and professional fees)
(i.e., the onset of a sudden and serious condition requiring immediate care)

$150 co-pay then 100%, waived if admitted
$150 co-pay then 100%, waived if admitted. Deductible waived
$150 co-pay then 100%, waived if admitted

Home Health Services

Medically Necessary services must be pre-authorized (40 days per year maximum)

100%
70% of R&C after deductible
100%

Hospice Care

Inpatient and Home Hospice

100% (4)
70% of R&C after deductible (4)
100%

Hospital Care

Inpatient Care, including inpatient maternity care/delivery
(semi-private, unless private room is Medically Necessary)

$300 co-pay per hospital admission, then 90% after deductible
$500 co-pay per admission then 70% of R&C after deductible (4)
$150 co-pay per hospital admission, then 100%

Other Inpatient Services

90% after deductible
70% of R&C after deductible (4)
100%

Inpatient Physician Services
(excluding surgical services)

90% after deductible
70% of R&C after deductible (4)
100%

Skilled Nursing/Rehabilitation Facility
(120 days per year combined for Medically Necessary services)

100% (4)
70% of R&C after deductible (4)
100%

Outpatient Services
(including outpatient testing prior to outpatient surgery)

100%
70% of R&C after deductible
100%

Outpatient Surgery Facility Charges
(including freestanding surgical centers)

100% (4)
70% of R&C after deductible (4)
100%

Immunizations And Inoculations

For communicable diseases

100%
70% of R&C after deductible
100%

Laboratory Tests

Laboratory Tests

100%
70% of R&C after deductible
100%

Mental Health & Substance Abuse Services

Outpatient Mental Health Care

$15 co-pay
70% of R&C after deductible
$15 co-pay

Inpatient Mental Health Care

$150 co-pay per hospital admission, then 100%
$500 co-pay per admission, then 70% of R&C after deductible (4)
$150 co-pay per hospital admission, then 100%

Outpatient Substance Abuse Care

$15 co-pay
70% of R&C after deductible
$15 co-pay

Inpatient Substance Abuse Care

$150 co-pay per hospital admission, then 100%
$500 co-pay per admission, then 70% of R&C after deductible (4)
$150 co-pay per hospital admission, then 100%

Partial Hospital Facility Services

$15 co-pay per day
70% of R&C after deductible (4)
$15 co-pay per day

Nutritional Counseling

Limited to 2 visits per calendar year (with additional visits if pre-authorized)

$15 co-pay
70% of R&C after deductible
$15 co-pay

Office Visits for Treatment of Illness or Injury

Primary Care Office Visit

$15 co-pay
70% of R&C after deductible
$15 co-pay

Specialty Care Office Visit

$40 co-pay
70% of R&C after deductible
$40 co-pay

Diagnostic Services and Treatment

100%
70% of R&C after deductible
100%

Preventive Services

Preventive Exam (PCP, GYN, and Well Child care)

100%
70% of R&C after deductible
100%

Diagnostic Services for Physical Exam

100%
70% of R&C after deductible
100%

Mammogram and Screening Colonoscopy

100%
70% of R&C after deductible
100%

Physical / Occupational Therapy

Medically Necessary (60 visits per year combined maximum) PT/OT authorization required (for visits 13-60) (2)

$10 co-pay
70% of R&C after deductible
$10 co-pay

Radiology Procedures

Advanced imaging including MRI, CT, and PET scans

$50 co-pay
70% of R&C after deductible
$50 co-pay

All other imaging studies, including X-ray and Ultrasound
(excludes ultrasounds for pregnancy)

$10 co-pay
70% of R&C after deductible
$10 co-pay

Reproductive Health

Physician office visits
(prenatal care only)

100%
70% of R&C after deductible
100%

Birthing centers
(licensed facility)

100%
70% of R&C after deductible
N/A

Inpatient Maternity Care & Delivery

1/1/13 — 6/30/13 - $150 co-pay per hospital admission, then 100%

7/1/13 — 12/31/13 - $300 co-pay per hospital admission, then 90% after deductible
$500 co-pay per admission then 70% of R&C after deductible (4)
$150 co-pay per hospital admission, then 100%

Sterilization (voluntary)

100%
70% of R&C after deductible
100%

Interruption of pregnancy

100%
70% of R&C after deductible
100%

In vitro fertilization and artificial insemination
(pre-certification required for all services and prescriptions. All criteria must be met) (1)

Available Under Hopkins Affiliated Provider Only
Available Under Hopkins Affiliated Provider Only
100% after separate $1,000 infertility deductible

Speech Therapy

Speech therapyŚnon-developmental Medically Necessary (30 visits per year maximum) (2)

$10 co-pay
70% of R&C after deductible
$10 co-pay

Surgical Procedures

Professional services for inpatient and outpatient surgery

90% for inpatient, after deductible, 100% for outpatient
70% of R&C after deductible
100%

Professional services for Medically Necessary reconstructive and/or surgically implanted prosthetic devices

90% for inpatient, after deductible, 100% for outpatient
70% of R&C after deductible
100%

Gastric Bypass Surgery
(pre-certification required)

Available Under Hopkins Affiliated Provider Only
Available Under Hopkins Affiliated Provider Only
100% after separate $1,000 deductible

Urgent Care Center

Physician Visit

$40 co-pay
70% of R&C after deductible
$40 co-pay

Diagnostic Services and Treatment

100%
70% of R&C after deductible
100%

Prescription Drugs

 
In Network Retail Pharmacy (30 day supply)
In Network Retail Pharmacy (90 day supply)
Mail Order (90 day supply)

Generic

$10
$30
$20

Preferred

$30
$90
$60

Non Preferred

$50
$150
$100

Specialty Medications

$50
Restrict to 30 day retail supply only

All benefits are subject to medical necessity.

This is not a complete description of benefits. For more information, please refer to the Summary Plan Description (SPD).

Key Terms

Hopkins Affiliated Facilities include:
  • Johns Hopkins Hospital
  • Johns Hopkins Bayview Medical Center
  • Howard County General Hospital
  • Suburban Hospital
  • Sibley Memorial Hospital
  • All Children's Hospital.

R&C Reasonable and Customary Charge - This is the usual fee charged by similar providers for the same services or supplies in the same geographic area. Johns Hopkins Employer Health Programs determines what is a Reasonable and Customary Charge. EHP Network providers (Option 1) will not charge more than the Reasonable and Customary Charge, but non-network providers can charge more.

(1) $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 Hopkins facilities only.

(2) Covered benefits only include therapy aimed at restoring the level of speech the individual had attained before the onset of a condition (i.e., before an illness or injury). Speech therapy for developmental disorders, such as stuttering, articulation disorders, tongue thrust, lisping, etc. is Not Covered.

(3) Services must be authorized by Care Management and prescribed, fitted and dispensed by licensed audiologist, replacement aids once every 36 months.

(4) Failure to obtain pre-certification may result in a penalty or possible denial of benefits.

(5) Co-pays are still required after you've reached your out of pocket maximum.