JHU Retirees Plan — 2022-2023
Medical Services and Supplies
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| EHP Network Provider | Out of Network Provider | |
|---|---|---|
| Acupuncture | ||
| Medically necessary services for anesthesia, pain control, and therapeutic purposes | 80% 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 tests | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Desensitization materials and serum | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Ambulance Transportation | ||
| Medically necessary ground transport | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Medically necessary air transport | 80% of allowed amount; deductible applies | 80% of allowed benefit; in-network deductible applies |
| Biofeedback | ||
| Biofeedback | 80% of allowed amount; deductible applies (pre-authorization required) | 70% of allowed benefit; deductible applies (pre-authorization required) |
| Chemo & Radiation Therapy | ||
| Physician visit | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Materials and treatment | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Chiropractic Care | ||
| Chiropractor restricted to initial exam, x-rays, and spinal manipulations | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Chiropractor with PT privileges (physical therapy services) | Refer to Therapy Section | Refer to Therapy Section |
| Dialysis | ||
| Medically necessary services | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Durable Medical Equipment | ||
| Breast pumps (standard) and related supplies | 100% of allowed amount; deductible waived | 70% of allowed benefit; deductible applies |
| Contraceptive devices | 100% of allowed amount; deductible waived | 70% of allowed benefit; deductible applies |
| Custom DME, including custom wheelchairs | 80% of allowed amount; deductible applies (pre-authorization required) | 70% of allowed benefit; deductible applies (pre-authorization required) |
| Custom-molded orthotics | 80% of allowed amount; deductible applies (pre-authorization required) | 70% of allowed benefit; deductible applies (pre-authorization required) |
| Insulin pumps, Continuous Glucose Monitor and related supplies | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Hearing aids | For 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 supplies | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Prosthetic devices | 80% of allowed amount; deductible applies (pre-authorization required) | 70% of allowed benefit; deductible applies (pre-authorization required) |
| Blood Pressure Cuff | 80% of allowed amount; deductible applies | 70% 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 applies | 80% of allowed benefit; in-network deductible applies |
| Home Health Services | ||
| Medically necessary services | 100% 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 therapy | 80% of allowed amount; deductible applies (pre-authorization required) | 70% of allowed benefit; deductible applies (pre-authorization required) |
| Hospice Care | ||
| Inpatient and home hospice | 80% 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 deductible | 70% of allowed benefit; after deductible |
| Skilled nursing/rehabilitation facility | 80% 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 rehabilitation | 80% 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 applies | 80% 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 services | 80% of allowed amount; deductible applies (pre-authorization required) | 70% of allowed benefit; deductible applies (pre-authorization required) |
| Immunizations | ||
| Preventive immunizations for communicable diseases | 100% of allowed amount; deductible waived | 70% of allowed benefit deductible waived |
| Travel immunizations | 100% of allowed amount; deductible waived | 70% of allowed benefit deductible waived |
| Infusion Therapy | ||
| Home infusion therapy | 80% of allowed amount; deductible applies (pre-authorization required) | 70% of allowed benefit; deductible applies (pre-authorization required) |
| Outpatient infusion therapy | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Injections | ||
| Injections | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Materials and serum | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Laboratory | ||
| Laboratory tests including pathology | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Mental Health & Substance Use Disorder Services | ||
| Outpatient mental health care (facility fees) | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Outpatient mental health care (professional fees) | 80% of allowed amount; deductible applies | 70% 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 applies | 70% of allowed benefit; deductible applies |
| Outpatient substance use disorder care (facility fees) | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Outpatient substance use disorder care (professional fees) | 80% of allowed amount; deductible applies | 70% 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 applies | 70% of allowed benefit; deductible applies |
| Intensive outpatient program | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Partial hospital facility services | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Medication management | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Mental health testing and procedures | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Methadone Treatment | ||
| Medically necessary outpatient care | 80% of allowed amount; deductible waived | 70% of allowed benefit; deductible applies |
| Nutritional Counseling | ||
| Medically necessary services | 80% 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 applies | 70% of allowed benefit; deductible applies |
| Primary care office visit (Pediatric: age 19 and under) | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Primary care office visit only (GYN) | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Specialty care office visit only (Adult & Pediatric) | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Treatment and diagnostic services in the office | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Preventive Services | ||
| Preventive exam (PCP, GYN and Well Child care) | 100% of allowed amount; deductible waived | 70% of allowed benefit; deductible waived |
| Diagnostic services for preventive exam | 100% of allowed amount; deductible waived | 70% of allowed benefit; deductible waived |
| Routine preventive screenings: mammogram, colonoscopy, PAP test, etc. | 100% of allowed amount; deductible waived | 70% of allowed benefit; deductible waived |
| Routine hearing exams | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Dermatological Screening | 100% 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 Nursing | Not Available | Not Available |
| Radiology Procedures | ||
| Advance imaging including MRI, CT and PET scans | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| All other imaging studies; including X-Ray and Ultrasound | 80% of allowed amount; deductible applies | 70% 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 applies | 70% of allowed benefit; deductible applies |
| Infertility treatment | 80% 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 applies | 70% of allowed benefit; deductible applies |
| Birthing centers (professional fees) | 80% of allowed amount; deductible applies | 70% 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 applies | 70% of allowed benefit; deductible applies |
| Interruption of pregnancy | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Female sterilization (professional services for surgery, anesthesia and related pathology) | 100% of allowed amount; deductible waived | 100% of allowed benefit; deductible waived |
| Male sterilization (professional services for surgery, anesthesia and related pathology) | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Surgical Procedures | ||
| Surgical treatment for morbid obesity | 80% of allowed amount; deductible applies (pre-authorization required) | 70% of allowed benefit; deductible applies (pre-authorization required) |
| Primary care office surgical procedures | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Specialist care office surgical procedures | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Outpatient surgery (including freestanding surgical centers) (facility fees) | 100% of allowed amount; deductible waived | 70% of allowed benefit; deductible applies |
| Outpatient surgery (including freestanding surgical centers) (professional fees) | 80% of allowed amount; deductible applies | 70% 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 | ||
| Telemedicine | 80% of allowed amount; deductible applies | 70% of allowed benefit; deductible applies |
| Therapy | ||
| Habilitative services for children under the age of 19 | 80% of allowed amount; deductible applies (pre-authorization required) | 70% of allowed benefit; deductible applies (pre-authorization required) |
| Physical therapy/occupational therapy medically necessary services | 80% 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 rehabilitation | 80% of allowed amount; deductible applies (pre-authorization required) | 70% of allowed benefit; deductible applies (pre-authorization required) |
| Cardiac rehabilitation | 80% of allowed amount; deductible applies (pre-authorization required) | 70% of allowed benefit; deductible applies (pre-authorization required) |
| Vision therapy | Not Available | Not 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 treatment | 100% of allowed amount; deductible waived | 100% of allowed benefit; deductible waived |
Revised
August 21, 2023
Group Number
E0005100 (*003C/*004C)
Plan Codes
225C0000
