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Johns Hopkins Bayview Medical Center PPO Plan — 2023

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EHP Preferred Network ProviderEHP Network ProviderOut of 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)70% of allowed benefit; deductible applies (20 visit annual maximum for all networks combined)
Allergy Tests & Procedures
Allergy tests90%, deductible applies80%, deductible applies70% of allowed benefit; deductible applies
Desensitization materials and serum90%, deductible applies80%, deductible applies70% of allowed benefit; deductible applies
Ambulance Transportation
Medically necessary ground transport100%, deductible applies100%, deductible applies100% of allowed benefit; deductible applies
Medically necessary air transport100%, deductible applies100%, deductible applies100% of allowed benefit; in-network deductible applies
Biofeedback
Biofeedback90%, deductible applies (pre-authorization required)80%, deductible applies (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Chemo & Radiation Therapy
Physician visit90%, deductible applies80%, deductible applies70% of allowed benefit; deductible applies
Materials and treatment90%, deductible applies80%, deductible applies70% of allowed benefit; 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)70% of allowed benefit; 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 Refer to Therapy Section
Diabetes Prevention Program
Program100% of allowed amount; deductible waived100% of allowed amount; deductible waived70% of allowed benefit; deductible applies
Dialysis
Medically necessary services90% at Fresenius/Davita Dialysis Centers; deductible applies 80%, deductible applies 70% of allowed benefit; deductible applies
Durable Medical Equipment
Breast pumps (standard) and related supplies100% for Johns Hopkins Home Care Group/Pharmaquip; deductible waived100%, deductible waived70% of allowed benefit; deductible applies
Contraceptive devices100%, deductible waived100%, deductible waived70% of allowed benefit; deductible applies
Custom DME, including custom wheelchairs90%, deductible applies (pre-authorization required)90%, deductible applies (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Custom-molded orthotics90%, deductible applies (pre-authorization required)80%, deductible applies (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Insulin pumps, Continuous Glucose Monitor and related supplies90%, deductible applies 90%, deductible applies 70% of allowed benefit; 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)70% of allowed benefit; 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 applies70% of allowed benefit; deductible applies
Prosthetic devices90%, deductible applies (pre-authorization required)90%, deductible applies (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Blood Pressure Cuff90%, deductible waived80%, deductible waived70% of allowed benefit, deductible applies
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$250 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%, deductible applies100%, deductible applies100% of allowed benefit; in-network deductible applies
Home Health Services
Medically necessary services90%, deductible applies (40 visit annual maximum for all networks combined; pre-authorization required)90%, deductible applies (40 visit annual maximum for all networks combined; pre-authorization required)70% of allowed benefit; 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)70% of allowed benefit; deductible applies (pre-authorization required)
Hospice Care
Inpatient and home hospice100%, deductible applies (pre-authorization required)100%, 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)$150 co-pay per admission, then 90%, deductible applies (semi-private, unless private room is medically necessary; pre-authorization required)$150 co-pay per admission, then 80%, deductible applies (semi-private, unless private room is medically necessary; pre-authorization required)$500 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)90%, deductible applies80%, deductible applies 70% of allowed benefit; 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)70% of allowed benefit; 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)70% of allowed benefit; 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)$250 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%, deductible applies100%, deductible applies100% of allowed benefit; deductible applies
Outpatient surgery & ambulatory surgical center (facility fees)90%, deductible applies (includes freestanding surgical centers)80%, deductible applies (includes freestanding surgical centers)70% of allowed benefit; deductible applies
Outpatient surgery & ambulatory surgical center (professional fees)90%, deductible applies80%, deductible applies 70% of allowed benefit; deductible applies
Hyperbaric Oxygen Therapy
Medically necessary services90%, deductible applies (pre-authorization required)80%, deductible applies (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Immunizations
Preventive immunizations for communicable diseases100%, deductible waived100%, deductible waived70% of allowed benefit; deductible applies
Travel immunizations100%, deductible waived100%, deductible waived70% of allowed benefit; deductible applies
Infusion Therapy
Home infusion therapy90% for services through Johns Hopkins Home Care Group, deductible applies (pre-authorization required)80%, deductible applies (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Outpatient infusion therapy90%, deductible applies80%, deductible applies70% of allowed benefit; deductible applies
Injections
Injections90%, deductible applies80%, deductible applies70% of allowed benefit; deductible applies
Materials and serum90%, deductible applies80%, deductible applies70% of allowed benefit; deductible applies
Laboratory
Laboratory tests including pathology90%, deductible applies80%, deductible applies70% of allowed benefit; deductible applies
Mental Health & Substance Use Disorder Services
Outpatient mental health care (facility fees)$10 co-pay, then 100%, deductible waived $10 co-pay, then 100%, deductible waived 70% of allowed benefit; deductible applies
Outpatient mental health care (professional fees)$10 co-pay, then 100%, deductible waived $10 co-pay, then 100%, deductible waived 70% of allowed benefit; deductible applies
Inpatient mental health care (facility fees)$150 co-pay per admission, then 90%, deductible applies (pre-authorization required)$150 co-pay per admission, then 80%, deductible applies (pre-authorization required)$500 co-pay per admission, then 70% of allowed benefit; deductible applies (pre-authorization required)
Inpatient mental health care (professional fees)90%, deductible applies80%, deductible applies 70% of allowed benefit; deductible applies
Outpatient substance use disorder care (facility fees)$10 co-pay, then 100%, deductible waived $10 co-pay, then 100%, deductible waived 70% of allowed benefit; deductible applies
Outpatient substance use disorder care (professional fees)$10 co-pay, then 100%, deductible waived $10 co-pay, then 100%, deductible waived 70% of allowed benefit; deductible applies
Inpatient substance use disorder care (facility fees)$150 co-pay per admission, then 90%, deductible applies (pre-authorization required)$150 co-pay per admission, then 80%, deductible applies (pre-authorization required)$500 co-pay per admission, then 70% of allowed benefit; deductible applies (pre-authorization required)
Inpatient substance use disorder care (professional fees)90%, deductible applies80%, deductible applies 70% of allowed benefit; deductible applies
Intensive outpatient program$10 co-pay per day, then 100%, deductible waived $10 co-pay per day, then 100%, deductible waived 70% of allowed benefit; deductible applies
Partial hospital facility services$10 co-pay per day, then 100%, deductible waived $10 co-pay per day, then 100%, deductible waived 70% of allowed benefit; deductible applies
Medication management$10 co-pay, then 100%, deductible waived $10 co-pay, then 100%, deductible waived 70% of allowed benefit; deductible applies
Mental health testing and procedures$10 co-pay, then 100%, deductible waived $10 co-pay, then 100%, deductible waived 70% of allowed benefit; deductible applies
Methadone Treatment
Medically necessary outpatient care$10 co-pay, then 100%, deductible waived $10 co-pay, then 100%, deductible waived 70% of allowed benefit; deductible applies
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)70% of allowed benefit; 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)Designated PCP: $10 co-pay; then 100%, deductible waived; Non-Designated Medical PCP: $20 co-pay; then 100%, deductible waivedDesignated Medical PCP: $10 co-pay; then 100%, deductible waived; Non-Designated Medical PCP: $20 co-pay; then 100%, deductible waived70% of allowed benefit; deductible applies
Primary care office visit (Pediatric: age 19 and under)Designated Medical PCP: $10 co-pay; then 100%, deductible waived; Non-Designated Medical PCP: $20 co-pay, then 100%, deductible waivedDesignated Medical PCP: $10 co-pay; then 100%, deductible waived; Non-Designated Medical PCP: $20 co-pay, then 100%, deductible waived70% of allowed benefit; deductible applies
Primary care office visit only (GYN)GYN PCPs: $10 co-pay, then 100%, deductible waived GYN PCPs: $10 co-pay, then 100%, deductible waived 70% of allowed benefit; deductible applies
Specialty care office visit only (Adult & Pediatric)90%, deductible applies80%, deductible applies70% of allowed benefit; deductible applies
Treatment and diagnostic services in the office90%, deductible applies80%, deductible applies70% of allowed benefit; deductible applies
Preventive Services
Preventive exam (PCP, GYN and Well Child care)100%, deductible waived100%, deductible waived70% of allowed benefit; deductible applies
Diagnostic services for preventive exam100%, deductible waived100%, deductible waived70% of allowed benefit; deductible applies
Routine preventive screenings: mammogram, colonoscopy, PAP test, etc.100%, deductible waived100%, deductible waived70% of allowed benefit; deductible applies
Routine hearing exams100%, deductible waived100%, deductible waived70% of allowed benefit; deductible applies
Private Duty Nursing
Private Duty NursingNot CoveredNot CoveredNot Covered
Radiology Procedures
All imaging studies including X-Ray, ultrasound, MRI, CT and PET scans90%, deductible applies80%, 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 appliesRoutine prenatal visits covered at 100%; all other pre-natal visits at 80% of allowed amount; deductible applies70% of allowed benefit; 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. Covered at Johns Hopkins Fertility Center and Shady Grove Fertility Center only
Birthing centers (facility fees)Not available90%, deductible applies70% of allowed benefit; deductible applies
Birthing centers (professional fees)90%, deductible applies80%, deductible applies70% of allowed benefit; deductible applies
Inpatient maternity care and delivery; newborn nursery care; NICU (facility fees)$150 co-pay per admission, then 90%, deductible applies (pre-authorization required)$150 co-pay per admission, then 80%, deductible applies (pre-authorization required)$500 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)90%, deductible applies80%, deductible applies70% of allowed benefit; deductible applies
Interruption of pregnancy90%, deductible applies80%, deductible applies70% of allowed benefit; deductible applies
Female sterilization (professional services for surgery, anesthesia and related pathology)100%, deductible waived100%, deductible waived70% of allowed benefit; deductible applies
Male sterilization (professional services for surgery, anesthesia and related pathology)100%, deductible waived100%, deductible waived70% of allowed benefit; deductible applies
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 onlyCovered at Johns Hopkins Bayview Medical Center and Sibley Memorial Hospital only
Primary care office surgical procedures90%, deductible applies80%, deductible applies70% of allowed benefit; deductible applies
Specialist care office surgical procedures90%, deductible applies80%, deductible applies70% of allowed benefit; deductible applies
Outpatient surgery (including freestanding surgical centers) (facility fees)90%, deductible applies80%, deductible applies70% of allowed benefit; deductible applies
Outpatient surgery (including freestanding surgical centers) (professional fees)90%, deductible applies80%, deductible applies70% of allowed benefit; deductible applies
Inpatient surgery (facility fees)$150 co-pay per admission, then 90%, deductible applies (pre-authorization required)$150 co-pay per admission, then 80%, deductible applies (pre-authorization required)$500 co-pay per admission, then 70% of allowed benefit; deductible applies (pre-authorization required)
Inpatient surgery (professional fees)90%, deductible applies80%, deductible applies70% of allowed benefit; deductible applies
Therapy
Habilitative services for children under the age of 1990%, deductible applies80%, deductible applies70% of allowed benefit; 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)70% of allowed benefit; 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)70% of allowed benefit; 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)70% of allowed benefit; deductible applies (pre-authorization required)
Cardiac rehabilitation90%, deductible applies (pre-authorization required)80%, deductible applies (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Vision therapyNot CoveredNot CoveredNot Covered
Urgent Care Center
Physician visit$25 co-pay; then 100%, deductible waived$25 co-pay; then 100%, deductible waived70% of allowed benefit; deductible applies
Diagnostic services and treatment100%, deductible waived100%, deductible waived70% of allowed benefit; deductible applies
Revised
October 12, 2022
Group Number
E00006, E00007, E00161
Plan Codes
Under $50K: JP1; $50K to $120K: JP3; $120K and over: JP5
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