JHU SHP Plan — 2022 – 2023
Vision Services and Supplies
For Members Under Age 20 Only
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| Johns Hopkins Routine Vision Care Network Providers | Out Of Network Providers | |
|---|---|---|
| Contact Lenses | ||
| Medically necessary | Up to $600 | Up to $225 |
| Elective | Up to $150, plus 15% discount on charges above $150 | Up to $75 |
| Materials | ||
| Single vision | 100% of allowed amount | Up to $25 |
| Bifocal | 100% of allowed amount ($0 copay – ultraviolet protective coating, standard progressive lenses, plastic photosensitive lenses) ($20 copay -blended segment lenses, photochromatic glass lenses) ($30 copay- intermediate vision lenses, polycarbonate lenses) ($35 copay – standard anti reflective coating) ($48 copay – premium anti reflective coating)($55 copay – hi-index lenses) ($60 copay – ultra anti reflective coating) ($70 copay select progressive lenses)($75 copay- polarized lenses) ($90 copay- premium progressive lenses) ($195 copay- ultra progressive lenses) | Up to $35 |
| Trifocal | 100% of allowed amount ($0 copay – ultraviolet protective coating, standard progressive lenses, plastic photosensitive lenses) ($20 copay – blended segment lenses, photochromatic glass lenses) ($30 copay- intermediate vision lenses, polycarbonate lenses) ($35 copay – standard anti reflective coating) ($48 copay – premium anti reflective coating)($55 copay – hi-index lenses) ($60 copay – ultra anti reflective coating) ($70 copay select progressive lenses)($75 copay- polarized lenses) ($90 copay- premium progressive lenses) ($195 copay- ultra progressive lenses) | Up to $45 |
| Lenticular | 100% of allowed amount ($0 copay – ultraviolet protective coating, standard progressive lenses, plastic photosensitive lenses) ($20 copay – blended segment lenses, photochromatic glass lenses) ($30 copay- intermediate vision lenses, polycarbonate lenses) ($35 copay – standard anti reflective coating) ($48 copay – premium anti reflective coating)($55 copay – hi-index lenses) ($60 copay – ultra anti reflective coating) ($70 copay select progressive lenses)($75 copay- polarized lenses) ($90 copay- premium progressive lenses) ($195 copay- ultra progressive lenses) | Up to $45 |
| Frames | Up to $150, plus 20% discount on charges above $150 | Up to $30 |
| Vision Exam | ||
| Vision Exam | 100% of allowed amount (one routine exam or contact lens fitting fee every 12 months; contact lens fitting fee may be provided in lieu of eye exam, but not in the same benefit year) | up to $30 (one routine exam or contact lens fitting fee every 12 months; contact lens fitting fee may be provided in lieu of eye exam, but not in the same benefit year) |
Revised
June 30, 2023
Group Number
E0001600
Plan Codes
803C0000
