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HCGH PPO Plan — 2023

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EHP Preferred Network Provider EHP Network Provider Out of Network Provider
Acupuncture
Medically necessary services for anesthesia, pain control, and therapeutic purposes 90%, 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 tests 90%, deductible applies 80%, deductible applies 70% of allowed benefit; deductible applies
Desensitization materials and serum 90%, deductible applies 80%, deductible applies 70% of allowed benefit; deductible applies
Ambulance Transportation
Medically necessary ground transport 100%, deductible applies 100%, deductible applies 100% of allowed benefit; deductible applies
Medically necessary air transport 100%, deductible applies 100%, deductible applies 100% of allowed benefit; in-network deductible applies
Biofeedback
Biofeedback 90%, deductible applies 80%, deductible applies 70% of allowed benefit; deductible applies
Chemo & Radiation Therapy
Physician visit 90%, deductible applies 80%, deductible applies 70% of allowed benefit; deductible applies
Materials and treatment 90%, deductible applies 80%, deductible applies 70% of allowed benefit; deductible applies
Chiropractic Care
Chiropractor restricted to initial exam, x-rays, and spinal manipulations 90%, 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
Program 100% of allowed amount; deductible waived 100% of allowed amount; deductible waived 70% of allowed benefit; deductible applies
Dialysis
Medically necessary services 90% at Fresenius/Davita Dialysis Centers; deductible applies 80%, deductible applies 70% of allowed benefit; deductible applies
Durable Medical Equipment
Breast pumps (standard) and related supplies 100% for Johns Hopkins Home Care Group/Pharmaquip; deductible waived 100%, deductible waived 70% of allowed benefit; deductible applies
Contraceptive devices 100%, deductible waived 100%, deductible waived 70% of allowed benefit; deductible applies
Custom DME, including custom wheelchairs 90%, deductible applies (pre-authorization required) 90%, deductible applies (pre-authorization required) 70% of allowed benefit; deductible applies (pre-authorization required)
Custom-molded orthotics 90%, deductible applies 80%, deductible applies 70% of allowed benefit; deductible applies
Insulin pumps, Continuous Glucose Monitor and related supplies 90%, deductible applies 90%, deductible applies 70% of allowed benefit; deductible applies
Hearing aids 90%, deductible applies (Covered only for dependent children under age 26; up to $1,400 per aid 90%, deductible applies (Covered only for dependent children under age 26; up to $1,400 per aid 70% of allowed benefit; deductible applies (Covered only for dependent children under age 26; up to $1,400 per aid
Non-custom medical equipment and supplies 90% for Johns Hopkins Home Care Group/Pharmaquip, deductible applies 80%, deductible applies 70% of allowed benefit; deductible applies
Prosthetic devices 90%, deductible applies (pre-authorization required) 90%, deductible applies (pre-authorization required) 70% of allowed benefit; deductible applies (pre-authorization required)
Blood Pressure Cuff 90%, deductible waived 80%, deductible waived 70% 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 applies 100%, deductible applies 100% of allowed benefit; in-network deductible applies
Home Health Services
Medically necessary services 90%, deductible applies (40 visit annual maximum for all networks combined 90%, deductible applies (40 visit annual maximum for all networks combined 70% of allowed benefit; deductible applies (40 visit annual maximum for all networks combined
Home infusion therapy 90% for services through Johns Hopkins Home Care Group, deductible applies 80%, deductible applies 70% of allowed benefit; deductible applies
Hospice Care
Inpatient and home hospice 100%, 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 applies 80%, deductible applies 70% of allowed benefit; deductible applies
Skilled nursing/rehabilitation facility 90%, 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 rehabilitation 90%, 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 applies 100%, deductible applies 100% 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 applies 80%, deductible applies 70% of allowed benefit; deductible applies
Hyperbaric Oxygen Therapy
Medically necessary services 90%, 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 diseases 100%, deductible waived 100%, deductible waived 70% of allowed benefit; deductible applies
Travel immunizations 100%, deductible waived 100%, deductible waived 70% of allowed benefit; deductible applies
Infusion Therapy
Home infusion therapy 90% 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 therapy 90%, deductible applies 80%, deductible applies 70% of allowed benefit; deductible applies
Injections
Injections 90%, deductible applies 80%, deductible applies 70% of allowed benefit; deductible applies
Materials and serum 90%, deductible applies 80%, deductible applies 70% of allowed benefit; deductible applies
Laboratory
Laboratory tests including pathology 90%, deductible applies 80%, deductible applies 70% 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 applies 80%, 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 applies 80%, 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 services 90%, deductible applies 80%, deductible applies 70% of allowed benefit; deductible applies
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 waived Designated Medical PCP: $10 co-pay; then 100%, deductible waived; Non-Designated Medical PCP: $20 co-pay; then 100%, deductible waived 70% 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 waived Designated Medical PCP: $10 co-pay; then 100%, deductible waived; Non-Designated Medical PCP: $20 co-pay, then 100%, deductible waived 70% 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 applies 80%, deductible applies 70% of allowed benefit; deductible applies
Treatment and diagnostic services in the office 90%, deductible applies 80%, deductible applies 70% of allowed benefit; deductible applies
Preventive Services
Preventive exam (PCP, GYN and Well Child care) 100%, deductible waived 100%, deductible waived 70% of allowed benefit; deductible applies
Diagnostic services for preventive exam 100%, deductible waived 100%, deductible waived 70% of allowed benefit; deductible applies
Routine preventive screenings: mammogram, colonoscopy, PAP test, etc. 100%, deductible waived 100%, deductible waived 70% of allowed benefit; deductible applies
Routine hearing exams 100%, deductible waived 100%, deductible waived 70% of allowed benefit; deductible applies
Private Duty Nursing
Private Duty Nursing Not Covered Not Covered Not Covered
Radiology Procedures
All imaging studies including X-Ray, ultrasound, MRI, CT and PET scans 90%, deductible applies 80%, deductible applies 70% 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 applies Routine prenatal visits covered at 100%; all other pre-natal visits at 80% of allowed amount; deductible applies 70% of allowed benefit; deductible applies
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. 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 available 90%, deductible applies 70% of allowed benefit; deductible applies
Birthing centers (professional fees) 90%, deductible applies 80%, deductible applies 70% 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 applies 80%, deductible applies 70% of allowed benefit; deductible applies
Interruption of pregnancy 90%, deductible applies 80%, deductible applies 70% of allowed benefit; deductible applies
Female sterilization (professional services for surgery, anesthesia and related pathology) 100%, deductible waived 100%, deductible waived 70% of allowed benefit; deductible applies
Male sterilization (professional services for surgery, anesthesia and related pathology) 100%, deductible waived 100%, deductible waived 70% of allowed benefit; deductible applies
Surgical Procedures
Surgical treatment for morbid obesity Covered 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 Covered at Johns Hopkins Bayview Medical Center and Sibley Memorial Hospital only
Primary care office surgical procedures 90%, deductible applies 80%, deductible applies 70% of allowed benefit; deductible applies
Specialist care office surgical procedures 90%, deductible applies 80%, deductible applies 70% of allowed benefit; deductible applies
Outpatient surgery (including freestanding surgical centers) (facility fees) 90%, deductible applies 80%, deductible applies 70% of allowed benefit; deductible applies
Outpatient surgery (including freestanding surgical centers) (professional fees) 90%, deductible applies 80%, deductible applies 70% 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 applies 80%, deductible applies 70% of allowed benefit; deductible applies
Therapy
Habilitative services for children under the age of 19 90%, deductible applies 80%, deductible applies 70% of allowed benefit; deductible applies
Physical therapy/occupational therapy medically necessary services 90%, deductible applies (60 visit annual maximum for all networks combined 80%, deductible applies (60 visit annual maximum for all networks combined 70% of allowed benefit; deductible applies (60 visit annual maximum for all networks combined
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 rehabilitation 90%, deductible applies 80%, deductible applies 70% of allowed benefit; deductible applies
Cardiac rehabilitation 90%, deductible applies 80%, deductible applies 70% of allowed benefit; deductible applies
Vision therapy Not Covered Not Covered Not Covered
Urgent Care Center
Physician visit $25 co-pay; then 100%, deductible waived $25 co-pay; then 100%, deductible waived 70% of allowed benefit; deductible applies
Diagnostic services and treatment 100%, deductible waived 100%, deductible waived 70% of allowed benefit; deductible applies
Revised
October 2, 2023
Group Number
E0008000
Plan Codes
Under $50K: JP1C0000; $50K to $120K: JP3C0000; $120K and over: JP5C0000
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