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Broadway Plan — 2022 – 2023

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EHP Network Provider Out of Network Provider
Acupuncture
Medically necessary services for anesthesia, pain control, and therapeutic purposes $25 co-pay, then 100% of allowed amount ($1000 annual maximum for all networks combined) 70% of allowed benefit; deductible applies ($1000 annual maximum for all networks combined)
Allergy Tests & Procedures
Allergy tests 100% of allowed amount 70% of allowed benefit; deductible applies
Desensitization materials and serum 100% of allowed amount 70% of allowed benefit; deductible applies
Ambulance Transportation
Medically necessary ground transport 100% of allowed amount 100% of allowed benefit; deductible applies
Medically necessary air transport Not Covered Not Covered
Biofeedback
Biofeedback Not Covered Not Covered
Chemo & Radiation Therapy
Physician visit 100% of allowed amount 70% of allowed benefit; deductible applies
Materials and treatment 100% of allowed amount 70% of allowed benefit; deductible applies
Chiropractic Care
Chiropractor restricted to initial exam, x-rays, and spinal manipulations $25 co-pay, then 100% of allowed amount ($1000 annual maximum for all networks combined) 70% of allowed benefit; deductible applies ($1000 annual maximum for all networks combined)
Chiropractor with PT privileges (physical therapy services) Refer to Therapy section Refer to Therapy section
Dialysis
Medically necessary services 100% of allowed amount 70% of allowed benefit; deductible applies
Durable Medical Equipment
Breast pumps (standard) and related supplies 100% of allowed amount (pre-authorization required) 70% of allowed benefit; deductible applies (pre-authorization required)
Contraceptive devices Not Covered Not Covered
Custom DME, including custom wheelchairs 100% of allowed amount (pre-authorization required) 70% of allowed benefit; deductible applies (pre-authorization required)
Custom-molded orthotics 100% of allowed amount (pre-authorization required) 70% of allowed benefit; deductible applies (pre-authorization required)
Insulin pumps, Continuous Glucose Monitor and related supplies 100% of allowed amount 70% of allowed benefit; deductible applies
Hearing aids Not Covered Not Covered
Non-custom medical equipment and supplies 100% of allowed amount 70% of allowed benefit; deductible applies
Prosthetic devices 100% of allowed amount (pre-authorization required) 70% of allowed benefit; deductible applies (pre-authorization required)
Blood Pressure Cuff 100% of allowed amount 70% of allowed benefit; deductible applies
Emergency Services
Emergency care (facility fees) $150 co-pay, then 100% of allowed amount (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage $150 co-pay, then 100% of allowed benefit; deductible waived (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage
Emergency care (professional fees) 100% of allowed amount 100% of allowed benefit; deductible waived
Home Health Services
Medically necessary services 100% of allowed amount (40 visits per year maximum for all networks combined; pre-authorization required) 70% of allowed benefit; deductible applies (40 visits per year maximum for all networks combined; pre-authorization required)
Home infusion therapy 100% of allowed amount 70% of allowed benefit; deductible applies
Hospice Care
Inpatient and home hospice 100% of allowed amount (pre-authorization required) 70% of allowed benefit; deductible applies (pre-authorization required)
Hospital Care
Inpatient care including newborn nursery care; NICU (facility fees) 100% of allowed amount (semi-private, unless private room is medically necessary; pre-authorization required) $100 co-pay per admission, then 70% of allowed benefit; deductible applies (semi-private, unless private room is medically necessary; pre-authorization required)
Inpatient care (professional fees) 100% of allowed amount 70% of allowed benefit; deductible applies
Skilled nursing/rehabilitation facility 100% of allowed amount (120 days per year maximum for all networks combined; pre-authorization required) 70% of allowed benefit; deductible applies (120 days per year maximum for all networks combined; pre-authorization required)
Short-term acute rehabilitation 100% of allowed amount (120 days per year maximum for all networks combined; pre-authorization required) 70% of allowed benefit; deductible applies (120 days per year maximum for all networks combined; pre-authorization required)
Observation care (facility fees) $135 co-pay, then 100% of allowed amount (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage $135 co-pay, then 100% of allowed benefit; deductible waived (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage
Observation care (professional fees) 100% of allowed amount 100% of allowed benefit; deductible waived
Outpatient surgery & ambulatory surgical center (facility fees) 100% of allowed amount (includes freestanding surgical centers) 70% of allowed benefit; deductible applies (includes freestanding surgical centers)
Outpatient surgery & ambulatory surgical center (professional fees) 100% of allowed amount 70% of allowed benefit; deductible applies
Hyperbaric Oxygen Therapy
Medically necessary services 100% of allowed amount (pre-authorization required) 70% of allowed benefit; deductible applies (pre-authorization required)
Immunizations
Preventive immunizations for communicable diseases 100% of allowed amount 70% of allowed benefit; deductible applies
Travel immunizations 100% of allowed amount 70% of allowed benefit; deductible applies
Infusion Therapy
Home infusion therapy 100% of allowed amount (pre-authorization required) 70% of allowed benefit; deductible applies (pre-authorization required)
Outpatient infusion therapy 100% of allowed amount 70% of allowed benefit; deductible applies
Injections
Injections 100% of allowed amount 70% of allowed benefit; deductible applies
Materials and serum 100% of allowed amount 70% of allowed benefit; deductible applies
Laboratory
Laboratory tests including pathology 100% of allowed amount 70% of allowed benefit; deductible applies
Mental Health & Substance Use Disorder Services
Outpatient mental health care (facility fees) 100% of allowed amount 70% of allowed benefit; deductible applies
Outpatient mental health care (professional fees) $15 co-pay, then 100% of allowed amount 70% of allowed benefit; deductible applies
Inpatient mental health care (facility fees) 100% of allowed amount (semi-private, unless private room is medically necessary; pre-authorization required) $100 co-pay per admission, then 70% of allowed benefit; deductible applies (semi-private, unless private room is medically necessary; pre-authorization required)
Inpatient mental health care (professional fees) 100% of allowed amount 70% of allowed benefit; deductible applies
Outpatient substance use disorder care (facility fees) 100% of allowed amount 70% of allowed benefit; deductible applies
Outpatient substance use disorder care (professional fees) $15 co-pay, then 100% of allowed amount 70% of allowed benefit; deductible applies
Inpatient substance use disorder care (facility fees) 100% of allowed amount (semi-private, unless private room is medically necessary; pre-authorization required) $100 co-pay per admission, then 70% of allowed benefit; deductible applies (semi-private, unless private room is medically necessary; pre-authorization required)
Inpatient substance use disorder care (professional fees) 100% of allowed amount 70% of allowed benefit; deductible applies
Intensive outpatient program $15 co-pay, then 100% of allowed amount 70% of allowed benefit; deductible applies
Partial hospital facility services $15 co-pay, then 100% of allowed amount 70% of allowed benefit; deductible applies
Medication management $15 co-pay, then 100% of allowed amount 70% of allowed benefit; deductible applies
Mental health testing and procedures $15 co-pay, then 100% of allowed amount 70% of allowed benefit; deductible applies
Methadone Treatment
Medically necessary outpatient care $15 co-pay, then 100% of allowed amount 70% of allowed benefit; deductible applies
Nutritional Counseling
Medically necessary services $25 co-pay, then 100% of allowed amount (limited to one initial consultation and one follow-up visit for all networks combined) 70% of allowed benefit; deductible applies (limited to one initial consultation and one follow-up visit for all networks combined)
Office Visits for Treatment of Illness or Injury
Primary care office visit only (Adult) $15 co-pay, then 100% of allowed amount 70% of allowed benefit; deductible applies
Primary care office visit (Pediatric: age 19 and under) $15 co-pay, then 100% of allowed amount 70% of allowed benefit; deductible applies
Primary care office visit only (GYN) $15 co-pay, then 100% of allowed amount 70% of allowed benefit; deductible applies
Specialty care office visit only (Adult & Pediatric) $25 co-pay, then 100% of allowed amount 70% of allowed benefit; deductible applies
Treatment and diagnostic services in the office 100% of allowed amount 70% of allowed benefit; deductible applies
Preventive Services
Preventive exam (PCP, GYN and Well Child care) $15 co-pay, then 100% of allowed amount 70% of allowed benefit; deductible applies
Diagnostic services for preventive exam 100% of allowed amount 70% of allowed benefit; deductible applies
Routine preventive screenings: mammogram, colonoscopy, PAP test, etc. 100% of allowed amount 70% of allowed benefit; deductible applies
Routine hearing exams 100% of allowed amount 70% of allowed benefit; deductible applies
Private Duty Nursing
Private Duty Nursing Not Covered Not Covered
Radiology Procedures
All imaging studies including X-Ray, ultrasound, MRI, CT and PET scans 100% of allowed amount 70% of allowed benefit; deductible applies
Reproductive Health
Physician office visits (prenatal care only) Routine prenatal visits and all other prenatal visits covered at 100% of allowed amount 70% of allowed benefit; deductible applies
Infertility treatment Not Covered Not Covered
Birthing centers (facility fees) 100% of allowed amount 70% of allowed benefit; deductible applies
Birthing centers (professional fees) 100% of allowed amount 70% of allowed benefit; deductible applies
Inpatient maternity care and delivery; newborn nursery care; NICU (facility fees) 100% of allowed amount (semi-private, unless private room is medically necessary; pre-authorization required) $100 co-pay per admission, then 70% of allowed benefit; deductible applies (semi-private, unless private room is medically necessary; pre-authorization required)
Inpatient maternity care and delivery; newborn nursery care; NICU (professional fees) 100% of allowed amount 70% of allowed benefit; deductible applies
Interruption of pregnancy 100% of allowed amount (pre-authorization required; life of mother, rape, or incest only) 70% of allowed benefit; deductible applies (pre-authorization required; life of mother, rape, or incest only)
Female sterilization (professional services for surgery, anesthesia and related pathology) 100% of allowed amount 70% of allowed benefit; deductible applies
Male sterilization (professional services for surgery, anesthesia and related pathology) 100% of allowed amount 70% of allowed benefit; deductible applies
Surgical Procedures
Surgical treatment for morbid obesity Not Covered Not Covered
Primary care office surgical procedures 100% of allowed amount 70% of allowed benefit; deductible applies
Specialist care office surgical procedures 100% of allowed amount 70% of allowed benefit; deductible applies
Outpatient surgery (including freestanding surgical centers) (facility fees) 100% of allowed amount 70% of allowed benefit; deductible applies
Outpatient surgery (including freestanding surgical centers) (professional fees) 100% of allowed amount 70% of allowed benefit; deductible applies
Inpatient surgery (facility fees) 100% of allowed amount (semi-private, unless private room is medically necessary; pre-authorization required) $100 co-pay per admission, then 70% of allowed benefit; deductible applies (semi-private, unless private room is medically necessary; pre-authorization required)
Inpatient surgery (professional fees) 100% of allowed amount 70% of allowed benefit; deductible applies
Therapy
Habilitative services for children under the age of 19 Not Covered Not Covered
Physical therapy/occupational therapy medically necessary services 100% of allowed amount (60 visits per year maximum for all networks combined) 70% of allowed benefit; deductible applies (60 visits per year maximum for all networks combined)
Speech therapy (non-developmental medically necessary services) 100% of allowed amount (30 visits per year maximum for all networks combined; pre-authorization required) 70% of allowed benefit; deductible applies (30 visits per year maximum for all networks combined; pre-authorization required)
Pulmonary rehabilitation 100% of allowed amount 70% of allowed benefit; deductible applies
Cardiac rehabilitation 100% of allowed amount 70% of allowed benefit; deductible applies
Vision therapy Not Covered Not Covered
Urgent Care Center
Physician visit $15 co-pay, then 100% of allowed amount 70% of allowed benefit; deductible applies
Diagnostic services and treatment 100% of allowed amount 70% of allowed benefit; deductible applies
Revised
December 1, 2022
Group Number
E0000800, E0000900
Plan Codes
112C0000, 603C0000
Available 24/7

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