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Johns Hopkins Bayview Medical Center EPO Plan — 2023

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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
Diabetes Prevention Program
Program100% of allowed benefit; deductible waived100% of allowed amount; deductible waived
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. 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.
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
October 12, 2022
Group Number
E00006, E00007, E00161
Plan Codes
JE1
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