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Suburban EPO Plan — 2023

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EHP Preferred Network Provider EHP 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)
Allergy Tests & Procedures
Allergy tests 90%, deductible applies 80%, deductible applies
Desensitization materials and serum 90%, deductible applies 80%, deductible applies
Ambulance Transportation
Medically necessary ground transport 90%, deductible applies 90%, deductible applies
Medically necessary air transport 90%, deductible applies 90%, deductible applies
Biofeedback
Biofeedback 90%, deductible applies 80%, deductible applies
Chemo & Radiation Therapy
Physician visit 90%, deductible applies 80%, deductible applies
Materials and treatment 90%, deductible applies 80%, 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)
Chiropractor with PT privileges (physical therapy services) Refer to Therapy Section Refer to Therapy Section
Diabetes Prevention Program
Program 100% of allowed benefit; deductible waived 100% of allowed amount; deductible waived
Dialysis
Medically necessary services 90% at Fresenius/Davita Dialysis Centers; deductible applies 80%, deductible applies
Durable Medical Equipment
Breast pumps (standard) and related supplies 100% for Johns Hopkins Home Care Group/Pharmaquip; deductible waived 100%, deductible waived
Contraceptive devices 100%, deductible waived 100%, deductible waived
Custom DME, including custom wheelchairs 90%, deductible applies (pre-authorization required) 90%, deductible applies (pre-authorization required)
Custom-molded orthotics 90%, deductible applies 80%, deductible applies
Insulin pumps, Continuous Glucose Monitor and related supplies 90%, deductible applies 90%, deductible applies
Hearing aids 90%, deductible applies (Covered only for dependent children under age 26; up to $1,400 per aid; 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; replacement aids once every 36 months all networks combined)
Non-custom medical equipment and supplies 90% for Johns Hopkins Home Care Group/Pharmaquip, deductible applies 80%, deductible applies
Prosthetic devices 90%, deductible applies (pre-authorization required) 90%, deductible applies (pre-authorization required)
Blood Pressure Cuff 90%, deductible waived 80%, 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 applies 100%, deductible applies
Home Health Services
Medically necessary services 90%, deductible applies (40 visit annual maximum for all networks combined 80%, 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
Hospice Care
Inpatient and home hospice 100%, deductible applies 100%, deductible applies
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 applies 80%, 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)
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)
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 applies 100%, 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 applies 80%, deductible applies
Hyperbaric Oxygen Therapy
Medically necessary services 90%, deductible applies (pre-authorization required) 80%, deductible applies (pre-authorization required)
Immunizations
Preventive immunizations for communicable diseases 100%, deductible waived 100%, deductible waived
Travel immunizations 100%, deductible waived 100%, deductible waived
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)
Outpatient infusion therapy 90%, deductible applies 80%, deductible applies
Injections
Injections 90%, deductible applies 80%, deductible applies
Materials and serum 90%, deductible applies 80%, deductible applies
Laboratory
Laboratory tests including pathology 90%, deductible applies 80%, 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 applies 80%, 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 applies 80%, 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 services 90%, deductible applies 80%, deductible applies
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 applies 80%, deductible applies
Treatment and diagnostic services in the office PCP office: 100%, deductible waived Specialty office 90% deductible applies PCP office: 100%, deductible waived Specialty office: 80%, deductible applies
Preventive Services
Preventive exam (PCP, GYN and Well Child care) 100%, deductible waived 100%, deductible waived
Diagnostic services for preventive exam 100%, deductible waived 100%, deductible waived
Routine preventive screenings: mammogram, colonoscopy, PAP test, etc. 100%, deductible waived 100%, deductible waived
Routine hearing exams 100%, deductible waived 100%, deductible waived
Private Duty Nursing
Private Duty Nursing Not Covered Not Covered
Radiology Procedures
All imaging studies including X-Ray, ultrasound, MRI, CT and PET scans 90%, deductible applies 80%, 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
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.
Birthing centers (facility fees) Not available 90%, deductible applies
Birthing centers (professional fees) 90%, deductible applies 80%, 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 applies 80%, deductible applies
Interruption of pregnancy 90%, deductible applies 80%, deductible applies
Female sterilization (professional services for surgery, anesthesia and related pathology) 100%, deductible waived 100%, deductible waived
Male sterilization (professional services for surgery, anesthesia and related pathology) 100%, deductible waived 100%, deductible waived
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
Primary care office surgical procedures 90%, deductible applies 80%, deductible applies
Specialist care office surgical procedures 90%, deductible applies 80%, deductible applies
Outpatient surgery (including freestanding surgical centers) (facility fees) 90%, deductible applies 80%, deductible applies
Outpatient surgery (including freestanding surgical centers) (professional fees) 90%, deductible applies 80%, 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 applies 80%, deductible applies
Therapy
Habilitative services for children under the age of 19 90%, deductible applies 80%, 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
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 rehabilitation 90%, deductible applies 80%, deductible applies
Cardiac rehabilitation 90%, deductible applies 80%, deductible applies
Vision therapy Not Covered Not Covered
Urgent Care Center
Physician visit $40 co-pay, then 100%, deductible waived $40 co-pay, then 100%, deductible waived
Diagnostic services and treatment 100%, deductible waived 100%, deductible waived
Revised
October 2, 2023
Group Number
E0007000
Plan Codes
JE1C0000
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