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Johns Hopkins University Retirees Plan — 2022-2023

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EHP Preferred Network ProviderOut of Network Provider
Acupuncture
Medically necessary services for anesthesia, pain control, and therapeutic purposes80% of allowed amount (15 visits annual maximum for all networks combined); deductible applies (Pre-authorization required)70% of allowed benefit; deductible applies (15 visits annual maximum for all networks combined )deductible applies (Pre-authorization required)
Allergy Tests & Procedures
Allergy tests80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Desensitization materials and serum80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Ambulance Transportation
Medically necessary ground transport80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Medically necessary air transport80% of allowed amount; deductible applies80% of allowed benefit; in-network deductible applies
Biofeedback
Biofeedback80% of allowed amount; deductible applies (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Chemo & Radiation Therapy
Physician visit80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Materials and treatment80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Chiropractic Care
Chiropractor restricted to initial exam, x-rays, and spinal manipulations80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Chiropractor with PT privileges (physical therapy services)Refer to Therapy Section Refer to Therapy Section
Dialysis
Medically necessary services80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Durable Medical Equipment
Breast pumps (standard) and related supplies100% of allowed amount; deductible waived70% of allowed benefit; deductible applies
Contraceptive devices100% of allowed amount; deductible waived70% of allowed benefit; deductible applies
Custom DME, including custom wheelchairs80% of allowed amount; deductible applies (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Custom-molded orthotics80% of allowed amount; deductible applies (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Insulin pumps, Continuous Glucose Monitor and related supplies80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Hearing aidsFor dependent children up to age 19: 80% of allowed amount; deductible applies, replacement aids once every 36 months (all networks combined) For members age 19 and over: 80% of allowed amount; deductible applies, $1,000 maximum benefit per ear every 36 months (all networks combined) For dependent children up to age 19: 70% of allowed benefit; deductible applies, replacement aids once every 36 months (all networks combined) For members age 19 and over: 70% of allowed benefit; deductible applies, $1,000 maximum benefit per ear every 36 months (all networks combined)
Non-custom medical equipment and supplies80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Prosthetic devices80% of allowed amount; deductible applies (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Blood Pressure Cuff80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Emergency Services
Emergency care (facility fees)$100 co-pay, then 100% of allowed amount; deductible waived (ER co-pay waived if admitted); See Inpatient Facility Care for coverage)$100 co-pay, then 100% of allowed benefit; deductible waived (ER co-pay waived if admitted; See Inpatient Facility Care for coverage)
Emergency care (professional fees)80% of allowed amount; deductible applies80% of allowed benefit; in-network deductible applies
Home Health Services
Medically necessary services100% of allowed amount; deductible waived (90 visits per year maximum for all networks combined; pre-authorization required)70% of allowed benefit; deductible applies (90 visits per year maximum for all networks combined; pre-authorization required)
Home infusion therapy80% of allowed amount; deductible applies (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Hospice Care
Inpatient and home hospice80% of allowed amount; deductible applies (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Hospital Care
Inpatient care including newborn nursery care; NICU (facility fees)$250 co-pay per admission, then 80% of allowed amount; deductible applies (semi-private, unless private room is medically necessary; pre-authorization required)$250 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)80% of allowed amount, after deductible70% of allowed benefit; after deductible
Skilled nursing/rehabilitation facility80% of allowed amount; deductible applies (120 days per year maximum all networks combined for medically necessary services; pre-authorization required)70% of allowed benefit; deductible applies (120 days per year maximum all networks combined for medically necessary services; pre-authorization required)
Short-term acute rehabilitation80% of allowed amount; deductible applies (120 days per year maximum all networks combined for medically necessary services; pre-authorization required)70% of allowed benefit; deductible applies (120 days per year maximum all networks combined for medically necessary services; pre-authorization required)
Observation care (facility fees)$100 co-pay, then 100% of allowed amount; deductible waived (ER co-pay waived if admitted); see Inpatient Facility Care for coverage$100 co-pay, then 100% of allowed amount; deductible waived (ER co-pay waived if admitted); see Inpatient Facility Care for coverage
Observation care (professional fees)80% of allowed amount; deductible applies80% of allowed benefit; deductible applies
Outpatient surgery & ambulatory surgical center (facility fees)100% of allowed amount; deductible waived (includes freestanding surgical centers)70% of allowed benefit; deductible applies (includes freestanding surgical centers)
Outpatient surgery & ambulatory surgical center (professional fees)80% of allowed amount; deductible applies (includes outpatient testing prior to outpatient surgery)70% of allowed benefit; deductible applies (includes outpatient testing prior to outpatient surgery)
Hyperbaric Oxygen Therapy
Medically necessary services80% of allowed amount; deductible applies (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Immunizations
Preventive immunizations for communicable diseases100% of allowed amount; deductible waived70% of allowed benefit deductible waived
Travel immunizations100% of allowed amount; deductible waived70% of allowed benefit deductible waived
Infusion Therapy
Home infusion therapy80% of allowed amount; deductible applies (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Outpatient infusion therapy80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Injections
Injections80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Materials and serum80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Laboratory
Laboratory tests including pathology80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Mental Health & Substance Use Disorder Services
Outpatient mental health care (facility fees)80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Outpatient mental health care (professional fees)80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Inpatient mental health care (facility fees)$250 co-pay per admission, then 80% of allowed amount; deductible applies (pre-authorization required)$250 co-pay per admission, then 70% of allowed benefit; deductible applies (pre-authorization required)
Inpatient mental health care (professional fees)80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Outpatient substance use disorder care (facility fees)80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Outpatient substance use disorder care (professional fees)80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Inpatient substance use disorder care (facility fees)$250 co-pay per admission, then 80% of allowed amount; deductible applies (pre-authorization required)$250 co-pay per admission, then 70% of allowed benefit; deductible applies (pre-authorization required)
Inpatient substance use disorder care (professional fees)80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Intensive outpatient program80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Partial hospital facility services80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Medication management80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Mental health testing and procedures80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Methadone Treatment
Medically necessary outpatient care80% of allowed amount; deductible waived70% of allowed benefit; deductible applies
Nutritional Counseling
Medically necessary services80% of allowed amount; deductible applies (limited to 2 visits per plan year for all networks combined)70% of allowed benefit; deductible applies (limited to 2 visits per plan year for all networks combined)
Office Visits for Treatment of Illness or Injury
Primary care office visit only (Adult)80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Primary care office visit (Pediatric: age 19 and under)80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Primary care office visit only (GYN)80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Specialty care office visit only (Adult & Pediatric)80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Treatment and diagnostic services in the office80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Preventive Services
Preventive exam (PCP, GYN and Well Child care)100% of allowed amount; deductible waived70% of allowed benefit; deductible waived
Diagnostic services for preventive exam100% of allowed amount; deductible waived70% of allowed benefit; deductible waived
Routine preventive screenings: mammogram, colonoscopy, PAP test, etc.100% of allowed amount; deductible waived70% of allowed benefit; deductible waived
Routine hearing exams80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Dermatological Screening100% of the allowed amount; deductible waived (One screening per year)70% of allowed benefit; deductible waived (One screening per year)
Private Duty Nursing
Private Duty NursingNot AvailableNot Available
Radiology Procedures
Advance imaging including MRI, CT and PET scans80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
All other imaging studies; including X-Ray and Ultrasound80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Reproductive Health
Physician office visits (prenatal care only)Routine prenatal visits covered at 100%; all other pre-natal visits at 80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Infertility treatment80% of allowed amount; deductible applies (maximum lifetime benefit: $100,000, medical and pharmacy combined; maximum of 6 attempts per live birth for artificial insemination and intrauterine insemination; maximum of 3 attempts per live birth for in vitro fertilization; pre-authorization required for all services)70% of allowed benefit; deductible applies (maximum lifetime benefit: $100,000, medical and pharmacy combined; maximum of 6 attempts per live birth for artificial insemination and intrauterine insemination; maximum of 3 attempts per live birth for in vitro fertilization; pre-authorization required for all services)
Birthing centers (facility fees)80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Birthing centers (professional fees)80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Inpatient maternity care and delivery; newborn nursery care; NICU (facility fees)$250 co-pay per admission, then 80% of allowed amount; deductible applies (pre-authorization required)$250 co-pay per admission, then 70% of allowed benefit; deductible applies (pre-authorization required)
Inpatient maternity care and delivery; newborn nursery care; NICU (professional fees)80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Interruption of pregnancy80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Female sterilization (professional services for surgery, anesthesia and related pathology)100% of allowed amount; deductible waived100% of allowed benefit; deductible waived
Male sterilization (professional services for surgery, anesthesia and related pathology)80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Surgical Procedures
Surgical treatment for morbid obesity80% of allowed amount; deductible applies (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Primary care office surgical procedures80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Specialist care office surgical procedures80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Outpatient surgery (including freestanding surgical centers) (facility fees)100% of allowed amount; deductible waived70% of allowed benefit; deductible applies
Outpatient surgery (including freestanding surgical centers) (professional fees)80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Inpatient surgery (facility fees)$250 co-pay per admission, then 100% of allowed amount; deductible waived (pre-authorization required)$250 co-pay per admission, then 70% of allowed benefit; deductible waived (pre-authorization required)
Inpatient surgery (professional fees)80% of allowed amount; deductible applies (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Telemedicine
Telemedicine80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Therapy
Habilitative services for children under the age of 1980% of allowed amount; deductible applies (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Physical therapy/occupational therapy medically necessary services80% of allowed amount; deductible applies (45 visits per year combined maximum for all networks)70% of allowed benefit; deductible applies (45 visits per year combined maximum for all networks)
Speech therapy (non-developmental medically necessary services)80% of allowed amount; deductible applies (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 rehabilitation80% of allowed amount; deductible applies (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Cardiac rehabilitation80% of allowed amount; deductible applies (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Vision therapyNot AvailableNot Available
Urgent Care Center
Physician visit$50 co-pay, then 100% of allowed amount, deductible waived$50 co-pay, then 100% of allowed benefit, deductible waived
Diagnostic services and treatment100% of allowed amount; deductible waived100% of allowed benefit; deductible waived
Revised
September 13, 2022
Group Number
E00051 (*003/*004
Plan Codes
225
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