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Johns Hopkins Student Health Program Plan — 2022 - 2023

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EHP Network ProviderOut of Network Provider
Acupuncture
Medically necessary services for anesthesia, pain control, and therapeutic purposes80% of allowed amount; deductible applies ($300 annual maximum for all networks combined)70% of allowed benefit; deductible applies ($300 annual maximum for all networks combined)
Allergy Tests & Procedures
Allergy tests90% of allowed amount; deductible applies90% of allowed benefit; deductible applies
Desensitization materials and serum80% of allowed amount; deductible applies80% of allowed benefit; deductible applies
Ambulance Transportation
Medically necessary ground transport100% of allowed amount; deductible applies100% of allowed benefit; deductible applies
Medically necessary air transport100% of allowed amount; deductible applies100% of allowed benefit; in-network deductible applies
Biofeedback
BiofeedbackNot CoveredNot Covered
Chemo & Radiation Therapy
Physician visit100% of allowed amount; deductible applies80% of allowed benefit; deductible applies
Materials and treatment80% of allowed amount; deductible applies80% of allowed benefit; deductible applies
Chiropractic Care
Chiropractor with PT privileges (physical therapy services)Refer to Therapy sectionRefer to Therapy section
Chiropractic services80% of allowed amount; deductible applies 80% of allowed benefit; deductible applies
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 (pre-authorization required)
Contraceptive devices100% of allowed amount; deductible waived80% of allowed benefit; deductible applies
Custom DME, including custom wheelchairs80% of allowed amount; deductible applies (pre-authorization required)80% of allowed benefit; deductible applies (pre-authorization required)
Custom-molded orthotics80% of allowed amount; deductible applies (pre-authorization required)80% of allowed benefit; deductible applies (pre-authorization required)
Insulin pumps, Continuous Glucose Monitor and related supplies80% of allowed amount; deductible applies 80% of allowed benefit; deductible applies
Hearing aids80% of allowed amount; deductible applies (pre-authorization required) replacement aids once every 36 months all networks combined80% of allowed benefit; deductible applies (pre-authorization required) replacement aids once every 36 months all networks combined
Non-custom medical equipment and supplies80% of allowed amount; deductible applies 80% of allowed benefit; deductible applies
Prosthetic devices80% of allowed amount; deductible applies (pre-authorization required)80% of allowed benefit; deductible applies (pre-authorization required)
Blood Pressure Cuff80% of allowed amount; deductible applies 80% of allowed benefit; deductible applies
Emergency Services
Emergency care (facility fees)$50 co-pay, then 100% of allowed amount; deductible applies (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage$50 co-pay, then 100% of allowed benefit; in-network deductible applies (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage
Emergency care (professional fees)100% of allowed amount: deductible applies100% of allowed benefit: in-network deductible applies
Home Health Services
Medically necessary services100% of allowed amount for first 90 visits per plan year, then 80% of allowed amount; deductible applies (pre-authorization required)90% of allowed benefit for first 90 visits per plan year, then 80% of allowed benefit; deductible applies (pre-authorization required)
Home infusion therapy90% of allowed amount; deductible applies (pre-authorization required) 90% of allowed benefit; deductible applies (pre-authorization required)
Hospice Care
Inpatient and home hospice100% of allowed amount (pre-authorization required)100% of allowed benefit (pre-authorization required)
Hospital Care
Inpatient care including newborn nursery care; NICU (facility fees)90% of allowed amount; deductible applies (semi-private, unless private room is medically necessary; pre-authorization required)90% of allowed benefit; deductible applies (semi-private, unless private room is medically necessary; pre-authorization required)
Inpatient care (professional fees)80% of allowed amount; deductible applies80% of allowed benefit; deductible applies
Skilled nursing/rehabilitation facility90% of allowed amount; deductible applies (pre-authorization required)90% of allowed benefit; deductible applies (pre-authorization required)
Short-term acute rehabilitation90% of allowed amount; deductible applies (semi-private, unless private room is medically necessary; pre-authorization required)90% of allowed benefit; deductible applies (semi-private, unless private room is medically necessary; pre-authorization required)
Observation care (facility fees)$50 co-pay, then 100% of allowed amount; deductible applies (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage$50 co-pay, then 100% of allowed benefit; deductible applies (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage
Observation care (professional fees)100% of allowed amount; deductible applies100% of allowed benefit; deductible applies
Outpatient surgery & ambulatory surgical center (facility fees)90% of allowed amount; deductible applies (includes freestanding surgical centers)90% of allowed benefit; deductible applies (includes freestanding surgical centers)
Outpatient surgery & ambulatory surgical center (professional fees)80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Hyperbaric Oxygen Therapy
Medically necessary services90% of allowed amount; deductible applies (pre-authorization required)90% of allowed benefit; deductible applies (pre-authorization required)
Immunizations
Preventive immunizations for communicable diseases100% of allowed amount; deductible waived70% of allowed benefit; deductible applies
Travel immunizationsNot CoveredNot Covered
Infusion Therapy
Home infusion therapy90% of allowed amount; deductible applies (pre-authorization required)90% of allowed benefit; deductible applies (pre-authorization required)
Outpatient infusion therapy90% of allowed amount; deductible applies90% of allowed benefit; deductible applies
Injections
Injections90% of allowed amount; deductible applies90% of allowed benefit; deductible applies
Materials and serum90% of allowed amount; deductible applies90% of allowed benefit; deductible applies
Laboratory
Laboratory tests including pathology90% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Mental Health & Substance Use Disorder Services
Outpatient mental health care (facility fees)90% of allowed amount; deductible applies90% of allowed benefit; deductible applies
Outpatient mental health care (professional fees)90% of allowed amount; deductible applies90% of allowed benefit; deductible applies
Inpatient mental health care (facility fees)100% of allowed amount for the first 30 days, then 90% of allowed amount; deductible applies (pre-authorization required)100% of allowed benefit for the first 30 days, then 90% of allowed benefit; deductible applies (pre-authorization required)
Inpatient mental health care (professional fees)80% of allowed amount; deductible applies80% of allowed benefit; deductible applies
Outpatient substance use disorder care (facility fees)90% of allowed amount; deductible applies90% of allowed benefit; deductible applies
Outpatient substance use disorder care (professional fees)100% of allowed amount; deductible applies80% of allowed benefit; deductible applies
Inpatient substance use disorder care (facility fees)100% of allowed amount for the first 30 days, then 90% of allowed amount; deductible applies (pre-authorization required)100% of allowed benefit for the first 30 days, then 90% of allowed benefit; deductible applies (pre-authorization required)
Inpatient substance use disorder care (professional fees)80% of allowed amount; deductible applies80% of allowed benefit; deductible applies
Intensive outpatient program90% of allowed amount; deductible applies90% of allowed benefit; deductible applies
Partial hospital facility services90% of allowed amount; deductible applies90% of allowed benefit; deductible applies
Medication management90% of allowed amount; deductible applies90% of allowed benefit; deductible applies
Mental health testing and procedures90% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Methadone Treatment
Medically necessary outpatient care90% of allowed amount; deductible applies90% of allowed benefit; deductible applies
Nutritional Counseling
Medically necessary services90% of allowed amount; deductible applies70% of allowed benefit; deductible applies
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)100% of allowed amount; deductible applies90% 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)90% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Treatment and diagnostic services in the office90% 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 waived (well child care limited to office visit, immunizations and PKU, flu vaccine, urinalysis and lead testing) 70% of allowed benefit; deductible applies (well child care 90% of allowed benefit, deductible applies limited to office visit, immunizations and PKU, flu vaccine, urinalysis and lead testing)
Diagnostic services for preventive exam100% of allowed amount; deductible waived (well child care limited to office visit, immunizations and PKU, flu vaccine, urinalysis and lead testing) 70% of allowed benefit; deductible applies (well child care 90% of allowed benefit, deductible applies, limited to office visit, immunizations and PKU, flu vaccine, urinalysis and lead testing)
Routine preventive screenings: mammogram, colonoscopy, PAP test, etc.100% of allowed amount; deductible waived (one PAP per 12-month period)70% of allowed benefit; deductible applies (one PAP per 12-month period) 90% of allowed benefit mammograms only
Routine hearing exams100% of allowed amount; deductible waived (Pediatric: age 19 and under)70% of allowed benefit; deductible applies (Pediatric: age 19 and under)
Private Duty Nursing
Private Duty NursingNot CoveredNot Covered
Radiology Procedures
All imaging studies including X-Ray, ultrasound, MRI, CT and PET scans90% 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 90% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Infertility treatmentCovered at EHP network providers only: 50% of allowed amount, deductible applies, plus a separate $1,500 lifetime ART treatment deductible, $100,000 lifetime ART treatment maximum combined including prescription drugs. No lifetime maximum benefit applied to AI/IUI (pre-authorization required for all services and prescriptions) Covered at EHP network providers only
Birthing centers (facility fees)90% of allowed amount; deductible applies (pre-authorization required)90% of allowed benefit; deductible applies (pre-authorization required)
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)90% of allowed amount; deductible applies (semi-private, unless private room is medically necessary; pre-authorization required)90% 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)80% of allowed amount; deductible applies (maternity care - delivery and anesthesia 90% of allowed amount; deductible applies) (newborn care - initial and discharge visits 90% of allowed amount; deductible applies) (newborn care - all other inpatient visits - 80% of allowed amount, deductible applies)70% of allowed benefit; deductible applies (maternity care - delivery and anesthesia 70% of allowed benefit; deductible applies) (newborn care - initial and discharge visits 90% of allowed benefit; deductible applies) (newborn care - all other inpatient visits - 80% of allowed benefit, deductible applies)
Interruption of pregnancy80% 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 waived80% of allowed benefit; deductible applies
Male sterilization (professional services for surgery, anesthesia and related pathology)100% of allowed amount; deductible waived80% 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 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)90% of allowed amount; deductible applies (includes freestanding surgical centers)90% of allowed benefit; deductible applies (includes freestanding surgical centers)
Outpatient surgery (including freestanding surgical centers) (professional fees)80% of allowed amount; deductible applies70% of allowed benefit; deductible applies
Inpatient surgery (facility fees)90% of allowed amount; deductible applies (semi-private, unless private room is medically necessary; pre-authorization required)90% of allowed benefit; deductible applies (semi-private, unless private room is medically necessary; 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)
Therapy
Physical therapy/occupational therapy medically necessary services80% of allowed amount; deductible applies (excludes maintenance therapy)80% of allowed benefit; deductible applies (excludes maintenance therapy)
Speech therapy (non-developmental medically necessary services)80% of allowed amount; deductible applies (pre-authorization required)80% of allowed benefit; deductible applies (pre-authorization required)
Pulmonary rehabilitation90% of allowed amount; deductible applies (pre-authorization required)90% of allowed benefit; deductible applies (pre-authorization required)
Cardiac rehabilitation90% of allowed amount; deductible applies (pre-authorization required)90% of allowed benefit; deductible applies (pre-authorization required)
Vision therapyNot CoveredNot Covered
Habilatative Services80% of allowed amount; deductible applies80% of allowed benefit; deductible applies
Urgent Care Center
Physician visit100% of allowed amount; deductible applies100% of allowed benefit; deductible applies
Diagnostic services and treatment100% of allowed amount; deductible applies100% of allowed benefit; deductible applies
Revised
September 9, 2022
Group Number
E00016
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