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Johns Hopkins Hospital/Johns Hopkins Health System Corporation EPO Plan — 2022

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EHP Preferred Network ProviderEHP Network Provider
Acupuncture
Medically necessary services for anesthesia, pain control, and therapeutic purposes90%, deductible applies (20 visit annual maximum for all networks combined)80%, deductible applies (20 visit annual maximum for all networks combined)
Allergy Tests & Procedures
Allergy tests90%, deductible applies80%, deductible applies
Desensitization materials and serum90%, deductible applies80%, deductible applies
Ambulance Transportation
Medically necessary ground transport90%, deductible applies90%, deductible applies
Medically necessary air transport90%, deductible applies90%, deductible applies
Biofeedback
Biofeedback90%, deductible applies (pre-authorization required)80%, deductible applies (pre-authorization required)
Chemo & Radiation Therapy
Physician visit90%, deductible applies80%, deductible applies
Materials and treatment90%, deductible applies80%, deductible applies
Chiropractic Care
Chiropractor restricted to initial exam, x-rays, and spinal manipulations90%, deductible applies (20 visit annual maximum for all networks combined)80%, deductible applies (20 visit annual maximum for all networks combined)
Chiropractor with PT privileges (physical therapy services)Refer to Therapy Section Refer to Therapy Section
Dialysis
Medically necessary services90% at Fresenius/Davita Dialysis Centers; deductible applies 80%, deductible applies
Durable Medical Equipment
Breast pumps (standard) and related supplies100% for Johns Hopkins Home Care Group/Pharmaquip; deductible waived100%, deductible waived
Contraceptive devices100%, deductible waived100%, deductible waived
Custom DME, including custom wheelchairs90%, deductible applies (pre-authorization required)90%, deductible applies (pre-authorization required)
Custom-molded orthotics90%, deductible applies (pre-authorization required)80%, deductible applies (pre-authorization required)
Insulin pumps, Continuous Glucose Monitor and related supplies90%, deductible applies 90%, deductible applies
Hearing aids90%, deductible applies (Covered only for dependent children under age 26; up to $1,400 per aid; pre-authorization required; replacement aids once every 36 months all networks combined)90%, deductible applies (Covered only for dependent children under age 26; up to $1,400 per aid; pre-authorization required; replacement aids once every 36 months all networks combined)
Non-custom medical equipment and supplies90% for Johns Hopkins Home Care Group/Pharmaquip, deductible applies80%, deductible applies
Prosthetic devices90%, deductible applies (pre-authorization required)90%, deductible applies (pre-authorization required)
Blood Pressure Cuff90%, deductible waived80%, deductible waived
Emergency Services
Emergency care (facility fees)$250 co-pay, then 100%, deductible applies (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage$250 co-pay, then 100%, deductible applies (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage
Emergency care (professional fees)100%, deductible applies100%, deductible applies
Home Health Services
Medically necessary services90%, deductible applies (40 visit annual maximum for all networks combined; pre-authorization required)80%, deductible applies (40 visit annual maximum for all networks combined; pre-authorization required)
Home infusion therapy90% for services through Johns Hopkins Home Care Group, deductible applies (pre-authorization required)80%, deductible applies (pre-authorization required)
Hospice Care
Inpatient and home hospice100%, deductible applies (pre-authorization required)100%, deductible applies (pre-authorization required)
Hospital Care
Inpatient care including newborn nursery care; NICU (facility fees)$250 co-pay per admission, then 90%, deductible applies (semi-private, unless private room is medically necessary; pre-authorization required)$250 co-pay per admission, then 80%, deductible applies (semi-private, unless private room is medically necessary; pre-authorization required)
Inpatient care (professional fees)90%, deductible applies80%, deductible applies
Skilled nursing/rehabilitation facility90%, deductible applies (120 day annual maximum all networks combined for medically necessary services; pre-authorization required)First 30 days annually covered at 90%, remaining days at 80%, deductible applies (120 day annual maximum all networks combined for medically necessary services; pre-authorization required)
Short-term acute rehabilitation90%, deductible applies (120 day annual maximum all networks combined for medically necessary services; pre-authorization required)First 30 days annually covered at 90%, remaining days at 80%, deductible applies (120 day annual maximum all networks combined for medically necessary services; pre-authorization required)
Observation care (facility fees)$250 co-pay, then 100%, deductible applies (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage$250 co-pay, then 100%, deductible applies (if admitted, ER co-pay waived; see Inpatient Facility Care for coverage)
Observation care (professional fees)100%, deductible applies100%, deductible applies
Outpatient surgery & ambulatory surgical center (facility fees)90%, deductible applies (includes freestanding surgical centers)80%, deductible applies (includes freestanding surgical centers)
Outpatient surgery & ambulatory surgical center (professional fees)90%, deductible applies80%, deductible applies
Hyperbaric Oxygen Therapy
Medically necessary services90%, deductible applies (pre-authorization required)80%, deductible applies (pre-authorization required)
Immunizations
Preventive immunizations for communicable diseases100%, deductible waived100%, deductible waived
Travel immunizations100%, deductible waived100%, deductible waived
Infusion Therapy
Home infusion therapy90% for services through Johns Hopkins Home Care Group, deductible applies (pre-authorization required)80%, deductible applies (pre-authorization required)
Outpatient infusion therapy90%, deductible applies80%, deductible applies
Injections
Injections90%, deductible applies80%, deductible applies
Materials and serum90%, deductible applies80%, deductible applies
Laboratory
Laboratory tests including pathology90%, deductible applies80%, deductible applies
Mental Health & Substance Use Disorder Services
Outpatient mental health care (facility fees)$20 co-pay, then 100%, deductible waived$20 co-pay, then 100%, deductible waived
Outpatient mental health care (professional fees)$20 co-pay, then 100%, deductible waived$20 co-pay, then 100%, deductible waived
Inpatient mental health care (facility fees)$250 co-pay per admission, then 90%, deductible applies (pre-authorization required)$250 co-pay per admission, then 80%, deductible applies (pre-authorization required)
Inpatient mental health care (professional fees)90%, deductible applies80%, deductible applies
Outpatient substance use disorder care (facility fees)$20 co-pay, then 100%, deductible waived$20 co-pay, then 100%, deductible waived
Outpatient substance use disorder care (professional fees)$20 co-pay, then 100%, deductible waived$20 co-pay, then 100%, deductible waived
Inpatient substance use disorder care (facility fees)$250 co-pay per admission, then 90%, deductible applies (pre-authorization required)$250 co-pay per admission, then 80%, deductible applies (pre-authorization required)
Inpatient substance use disorder care (professional fees)90%, deductible applies80%, deductible applies
Intensive outpatient program$20 co-pay per day, then 100%, deductible waived $20 co-pay per day, then 100%, deductible waived
Partial hospital facility services$20 co-pay per day, then 100%, deductible waived $20 co-pay per day, then 100%, deductible waived
Medication management$20 co-pay, then 100%, deductible waived$20 co-pay, then 100%, deductible waived
Mental health testing and procedures$20 co-pay, then 100%, deductible waived$20 co-pay, then 100%, deductible waived
Methadone Treatment
Medically necessary outpatient care$20 co-pay, then 100%, deductible waived$20 co-pay, then 100%, deductible waived
Nutritional Counseling
Medically necessary services90%, deductible applies (limited to 6 visits per plan year for all networks combined)80%, deductible applies (limited to 6 visits per plan year for all networks combined)
Office Visits for Treatment of Illness or Injury
Primary care office visit only (Adult)$20 co-pay, then 100%, deductible waived$20 co-pay, then 100%, deductible waived
Primary care office visit (Pediatric: age 19 and under)$20 co-pay, then 100%, deductible waived$20 co-pay, then 100%, deductible waived
Primary care office visit only (GYN)GYN PCPs: $20 co-pay, then 100%, deductible waived GYN PCPs: $20 co-pay, then 100%, deductible waived
Specialty care office visit only (Adult & Pediatric)90%, deductible applies80%, deductible applies
Treatment and diagnostic services in the officePCP office: 100%, deductible waived Specialty office: 90%, deductible appliesPCP office: 100%, deductible waived Specialty office: 80%, deductible applies
Preventive Services
Preventive exam (PCP, GYN and Well Child care)100%, deductible waived100%, deductible waived
Diagnostic services for preventive exam100%, deductible waived100%, deductible waived
Routine preventive screenings: mammogram, colonoscopy, PAP test, etc.100%, deductible waived100%, deductible waived
Routine hearing exams100%, deductible waived100%, deductible waived
Private Duty Nursing
Private Duty NursingNot CoveredNot Covered
Radiology Procedures
All imaging studies including X-Ray, ultrasound, MRI, CT and PET scans90%, deductible applies80%, 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 appliesRoutine prenatal visits covered at 100%; all other pre-natal visits at 80% of allowed amount; deductible applies
Infertility treatmentCovered at the Johns Hopkins Fertility Center and Shady Grove Fertility Center only: 90%, deductible applies, plus a separate $1,000 lifetime infertility treatment deductible (pre-authorization required for all services and prescriptions; all criteria must be met; $30,000 lifetime medical maximum (including lab work and x-rays) and a separate $30,000 lifetime prescription maximum. In vitro fertilization attempts limited to a maximum of three per lifetime and artificial insemination limited to 6 attempts per live birth within the $60,000 lifetime medical and prescription maximum. The member must be enrolled in the EHP Plan for one year before beginning infertility treatment.)Covered at the Johns Hopkins Fertility Center and Shady Grove Fertility Center only: 90%, deductible applies, plus a separate $1,000 lifetime infertility treatment deductible (pre-authorization required for all services and prescriptions; all criteria must be met; $30,000 lifetime medical maximum (including lab work and x-rays) and a separate $30,000 lifetime prescription maximum. In vitro fertilization attempts limited to a maximum of three per lifetime and artificial insemination limited to 6 attempts per live birth within the $60,000 lifetime medical and prescription maximum. The member must be enrolled in the EHP Plan for one year before beginning infertility treatment.)
Birthing centers (facility fees)Not available90%, deductible applies
Birthing centers (professional fees)90%, deductible applies80%, deductible applies
Inpatient maternity care and delivery; newborn nursery care; NICU (facility fees)$250 co-pay per admission, then 90%, deductible applies (pre-authorization required)$250 co-pay per admission, then 80%, deductible applies (pre-authorization required)
Inpatient maternity care and delivery; newborn nursery care; NICU (professional fees)90%, deductible applies80%, deductible applies
Interruption of pregnancy90%, deductible applies80%, deductible applies
Female sterilization (professional services for surgery, anesthesia and related pathology)100%, deductible waived100%, deductible waived
Male sterilization (professional services for surgery, anesthesia and related pathology)100%, deductible waived100%, deductible waived
Surgical Procedures
Surgical treatment for morbid obesityCovered at Johns Hopkins Bayview Medical Center and Sibley Memorial Hospital only; $150 facility co-pay, deductible applies; then 90% for professional fees; deductible applies (pre-authorization required)Covered at Johns Hopkins Bayview Medical Center and Sibley Memorial Hospital only
Primary care office surgical procedures90%, deductible applies80%, deductible applies
Specialist care office surgical procedures90%, deductible applies80%, deductible applies
Outpatient surgery (including freestanding surgical centers) (facility fees)90%, deductible applies80%, deductible applies
Outpatient surgery (including freestanding surgical centers) (professional fees)90%, deductible applies80%, deductible applies
Inpatient surgery (facility fees)$250 co-pay per admission, then 90%, deductible applies (pre-authorization required)$250 co-pay per admission, then 80%, deductible applies (pre-authorization required)
Inpatient surgery (professional fees)90%, deductible applies80%, deductible applies
Therapy
Habilitative services for children under the age of 1990%, deductible applies 80%, deductible applies
Physical therapy/occupational therapy medically necessary services90%, deductible applies (60 visit annual maximum for all networks combined; PT/OT pre-authorization required for visits 13-60)80%, deductible applies (60 visit annual maximum for all networks combined; PT/OT pre-authorization required for visits 13-60)
Speech therapy (non-developmental medically necessary services)90%, deductible applies (30 visit annual maximum for all networks combined; pre-authorization required)80%, deductible applies (30 visit annual maximum for all networks combined; pre-authorization required)
Pulmonary rehabilitation90%, deductible applies (pre-authorization required)80%, deductible applies (pre-authorization required)
Cardiac rehabilitation90%, deductible applies (pre-authorization required)80%, deductible applies (pre-authorization required)
Vision therapyNot CoveredNot Covered
Urgent Care Center
Physician visit$40 co-pay, then 100%, deductible waived$40 co-pay, then 100%, deductible waived
Diagnostic services and treatment100%, deductible waived100%, deductible waived
Revised
September 15, 2022
Group Number
E00090, E00091, E00092, E00093, E00190, E00192, E00194, E00198
Plan Codes
JE1
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