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2024 Johns Hopkins DPC Plan

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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% (95% with DPC PCP Referral), deductible applies (20 visit annual maximum for all networks combined) 80% (85% with DPC PCP Referral), 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% (95% with DPC PCP Referral), deductible applies 80% (85% with DPC PCP Referral), deductible applies 70% of allowed benefit; deductible applies
Desensitization materials and serum 90% (95% with DPC PCP Referral), deductible applies 80% (85% with DPC PCP Referral), 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% (95% with DPC PCP Referral), deductible applies 80% (85% with DPC PCP Referral), deductible applies 70% of allowed benefit; deductible applies
Chemo & Radiation Therapy
Physician visit 90% (95% with DPC PCP Referral), deductible applies 80% (85% with DPC PCP Referral), deductible applies 70% of allowed benefit; deductible applies
Materials and treatment 90% (95% with DPC PCP Referral), deductible applies 80% (85% with DPC PCP Referral), deductible applies 70% of allowed benefit; deductible applies
Chiropractic Care
Chiropractor restricted to initial exam, x-rays, and spinal manipulations 90% (95% with DPC PCP Referral), deductible applies (20 visit annual maximum for all networks combined) 80% (85% with DPC PCP Referral), 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% (95% with DPC PCP Referral) at Fresenius/Davita Dialysis Centers; deductible applies 80% (85% with DPC PCP Referral), 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% (95% with DPC PCP Referral), deductible applies (pre-authorization required) 90% (95% with DPC PCP Referral), deductible applies (pre-authorization required) 70% of allowed benefit; deductible applies (pre-authorization required)
Custom-molded orthotics 90% (95% with DPC PCP Referral), deductible applies 80% (85% with DPC PCP Referral), deductible applies 70% of allowed benefit; deductible applies
Insulin pumps, Continuous Glucose Monitor and related supplies 90% (95% with DPC PCP Referral), deductible applies 90% (85% with DPC PCP Referral), deductible applies 70% of allowed benefit; deductible applies
Hearing aids 90% (95% with DPC PCP Referral), 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% (95% with DPC PCP Referral), 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) 70% of allowed benefit; 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% (95% with DPC PCP Referral) for Johns Hopkins Home Care Group/Pharmaquip, deductible applies 80% (85% with DPC PCP Referral), deductible applies 70% of allowed benefit; deductible applies
Prosthetic devices 90% (95% with DPC PCP Referral), deductible applies (pre-authorization required) 90% (95% with DPC PCP Referral), deductible applies (pre-authorization required) 70% of allowed benefit; deductible applies (pre-authorization required)
Blood Pressure Cuff 90% (95% with DPC PCP Referral), deductible waived 80% (85% with DPC PCP Referral), 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% (95% with DPC PCP Referral), deductible applies (40 visit annual maximum for all networks combined) 90% (95% with DPC PCP Referral), 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% (95% with DPC PCP Referral) for services through Johns Hopkins Home Care Group, deductible applies 80% (85% with DPC PCP Referral), deductible applies 70% of allowed benefit; deductible applies
Hospice Care
Inpatient and home hospice 100%, deductible applies 100%, deductible applies 70% of allowed benefit; deductible applies
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% (95% with DPC PCP Referral), deductible applies (includes freestanding surgical centers) 80% (95% with DPC PCP Referral), deductible applies (includes freestanding surgical centers) 70% of allowed benefit; deductible applies
Outpatient surgery & ambulatory surgical center (professional fees) 90% (95% with DPC PCP Referral), deductible applies 80% (95% with DPC PCP Referral), deductible applies 70% of allowed benefit; deductible applies
Hyperbaric Oxygen Therapy
Medically necessary services 90% (95% with DPC PCP Referral), deductible applies (pre-authorization required) 80% (85% with DPC PCP Referral), 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% (95% with DPC PCP Referral) for services through Johns Hopkins Home Care Group, deductible applies 80% (85% with DPC PCP Referral), deductible applies 70% of allowed benefit; deductible applies
Outpatient infusion therapy 90% (95% with DPC PCP Referral), deductible applies 80% (85% with DPC PCP Referral), deductible applies 70% of allowed benefit; deductible applies
Injections
Injections 90% (95% with DPC PCP Referral), deductible applies 80% (85% with DPC PCP Referral), deductible applies 70% of allowed benefit; deductible applies
Materials and serum 90% (95% with DPC PCP Referral), deductible applies 80% (85% with DPC PCP Referral), deductible applies 70% of allowed benefit; deductible applies
Laboratory
Laboratory tests including pathology 90% (95% with DPC PCP Referral), deductible applies 80% (85% with DPC PCP Referral), deductible applies 70% of allowed benefit; deductible applies
Mental Health & Substance Use Disorder Services
Outpatient mental health care (facility fees) $5 co-pay, then 100%, deductible waived $5 co-pay, then 100%, deductible waived 70% of allowed benefit; deductible applies
Outpatient mental health care (professional fees) $5 co-pay, then 100%, deductible waived $5 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) $5 co-pay, then 100%, deductible waived $5 co-pay, then 100%, deductible waived 70% of allowed benefit; deductible applies
Outpatient substance use disorder care (professional fees) $5 co-pay, then 100%, deductible waived $5 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 $5 co-pay per day, then 100%, deductible waived $5 co-pay per day, then 100%, deductible waived 70% of allowed benefit; deductible applies
Partial hospital facility services $5 co-pay per day, then 100%, deductible waived $5 co-pay per day, then 100%, deductible waived 70% of allowed benefit; deductible applies
Medication management $5 co-pay, then 100%, deductible waived $5 co-pay, then 100%, deductible waived 70% of allowed benefit; deductible applies
Mental health testing and procedures $5 co-pay, then 100%, deductible waived $5 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% (95% with DPC PCP Referral), deductible applies 80% (85% with DPC PCP Referral), deductible applies 70% of allowed benefit; deductible applies
Office Visits for Treatment of Illness or Injury
Primary care office visit only (Adult with DPC as PCP) DPC visit: $0 co-pay; then 100%, deductible waived Not Applicable Not Applicable
Primary care office visit only (Spouse/Dependent without DPC as PCP) $10 co-pay; then 100%, deductible waived $10 co-pay; then 100%, deductible waived 70% of allowed benefit; deductible applies
Primary care office visit (Pediatric: age 19 and under — Dependent without DPC as PCP) $10 co-pay; then 100%, deductible waived $10 co-pay; then 100%, deductible waived 70% of allowed benefit; deductible applies
Primary care office visit only (GYN) (Adult with DPC as PCP) DPC visit: $0 co-pay, Non-DPC GYN visit: $10 co-pay, 100%, deductible waived GYN visit: $10 co-pay, 100%, deductible waived 70% of allowed benefit; deductible applies
Primary care office visit only (GYN) (Spouse/Dependent without DPC as PCP) GYN: $10 co-pay, then 100%, deductible waived GYN: $10 co-pay, then 100%, deductible waived 70% of allowed benefit; deductible applies
Specialty care office visit only (Adult & Pediatric) 90% (95% with DPC PCP Referral), deductible applies 80% (85% with DPC PCP Referral), deductible applies 70% of allowed benefit; deductible applies
Treatment and diagnostic services in the office (Adult with DPC as PCP) DPC visit: $0 co-pay, 100%, deductible waived Not Applicable Not Applicable
Treatment and diagnostic services in the office (Spouse/Dependent without DPC as PCP) 90% (95% with DPC PCP Referral), deductible applies 80% (85% with DPC PCP Referral), deductible applies 70% of allowed benefit; deductible applies
Preventive Services
Preventive Services Preventive exam (PCP, GYN and Well Child care) (Adult with DPC as PCP) 100%, deductible waived Not Applicable Not Applicable
Preventive exam (PCP, GYN and Well Child care) (Spouse/Dependent without DPC as PCP) 100%, deductible waived 100%, deductible waived 70% of allowed benefit; deductible applies
Diagnostic services for preventive exam (Adult with DPC as PCP) 100%, deductible waived Not Applicable Not Applicable
Diagnostic services for preventive exam (Spouse/Dependent without DPC as PCP) 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% (95% with DPC PCP Referral), deductible applies 80% (85% with DPC PCP Referral), 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% (95% with DPC PCP Referral) of allowed amount; deductible applies Routine prenatal visits covered at 100%; all other pre-natal visits at 80% (85% with DPC PCP Referral) 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% (95% with DPC PCP Referral), deductible applies, plus a separate $1,000 lifetime infertility treatment deductible. There is a $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. Pre-authorization required. Covered at the Johns Hopkins Fertility Center and Shady Grove Fertility Center only: 90% (95% with DPC PCP Referral), deductible applies, plus a separate $1,000 lifetime infertility treatment deductible. There is a $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. Pre-authorization required. Covered at Johns Hopkins Fertility Center and Shady Grove Fertility Center only
Birthing centers (facility fees) Not available 90% (95% with DPC PCP Referral), deductible applies 70% of allowed benefit; deductible applies
Birthing centers (professional fees) 90% (95% with DPC PCP Referral), deductible applies 80% (85% with DPC PCP Referral), 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% (95% with DPC PCP Referral), deductible applies 80% (85% with DPC PCP Referral), 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% (95% with DPC PCP Referral), deductible applies 80% (85% with DPC PCP Referral), deductible applies 70% of allowed benefit; deductible applies
Specialist care office surgical procedures 90% (95% with DPC PCP Referral), deductible applies 80% (85% with DPC PCP Referral), deductible applies 70% of allowed benefit; deductible applies
Outpatient surgery (including freestanding surgical centers) (facility fees) 90% (95% with DPC PCP Referral), deductible applies 80% (85% with DPC PCP Referral), deductible applies 70% of allowed benefit; deductible applies
Outpatient surgery (including freestanding surgical centers) (professional fees) 90% (95% with DPC PCP Referral), deductible applies 80% (85% with DPC PCP Referral), 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
Telemedicine
Johns Hopkins OnDemand virtual Care 100%, deductible waived Not Applicable Not Applicable
Medical Advice Messaging $5 co-pay, deductible waived $5 co-pay, deductible waived 70% of allowed benefit; deductible applies
All Other Virtual Care Refer to specific covered benefit section Refer to specific covered benefit section Refer to specific covered benefit section
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% (95% with DPC PCP Referral), deductible applies (60 visit annual maximum for all networks combined) 80% (85% with DPC PCP Referral), 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% (95% with DPC PCP Referral), deductible applies (30 visit annual maximum for all networks combined) 80% (85% with DPC PCP Referral), deductible applies (30 visit annual maximum for all networks combined) 70% of allowed benefit; deductible applies (30 visit annual maximum for all networks combined)
Pulmonary rehabilitation 90% (95% with DPC PCP Referral), deductible applies 80% (85% with DPC PCP Referral), deductible applies 70% of allowed benefit; deductible applies
Cardiac rehabilitation 90% (95% with DPC PCP Referral), deductible applies 80% (85% with DPC PCP Referral), 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
August 26, 2024
Plan Codes
Under $50K: JD1C0000; $50K to $120K: JD3C0000; $120K and over: JD5C0000
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