Broadway Plan — 2022 – 2023
Medical Services and Supplies
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| EHP Network Provider | Out of Network Provider | |
|---|---|---|
| Acupuncture | ||
| Medically necessary services for anesthesia, pain control, and therapeutic purposes | $25 co-pay, then 100% of allowed amount ($1000 annual maximum for all networks combined) | 70% of allowed benefit; deductible applies ($1000 annual maximum for all networks combined) |
| Allergy Tests & Procedures | ||
| Allergy tests | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Desensitization materials and serum | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Ambulance Transportation | ||
| Medically necessary ground transport | 100% of allowed amount | 100% of allowed benefit; deductible applies |
| Medically necessary air transport | Not Covered | Not Covered |
| Biofeedback | ||
| Biofeedback | Not Covered | Not Covered |
| Chemo & Radiation Therapy | ||
| Physician visit | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Materials and treatment | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Chiropractic Care | ||
| Chiropractor restricted to initial exam, x-rays, and spinal manipulations | $25 co-pay, then 100% of allowed amount ($1000 annual maximum for all networks combined) | 70% of allowed benefit; deductible applies ($1000 annual maximum for all networks combined) |
| Chiropractor with PT privileges (physical therapy services) | Refer to Therapy section | Refer to Therapy section |
| Dialysis | ||
| Medically necessary services | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Durable Medical Equipment | ||
| Breast pumps (standard) and related supplies | 100% of allowed amount (pre-authorization required) | 70% of allowed benefit; deductible applies (pre-authorization required) |
| Contraceptive devices | Not Covered | Not Covered |
| Custom DME, including custom wheelchairs | 100% of allowed amount (pre-authorization required) | 70% of allowed benefit; deductible applies (pre-authorization required) |
| Custom-molded orthotics | 100% of allowed amount (pre-authorization required) | 70% of allowed benefit; deductible applies (pre-authorization required) |
| Insulin pumps, Continuous Glucose Monitor and related supplies | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Hearing aids | Not Covered | Not Covered |
| Non-custom medical equipment and supplies | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Prosthetic devices | 100% of allowed amount (pre-authorization required) | 70% of allowed benefit; deductible applies (pre-authorization required) |
| Blood Pressure Cuff | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Emergency Services | ||
| Emergency care (facility fees) | $150 co-pay, then 100% of allowed amount (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage | $150 co-pay, then 100% of allowed benefit; deductible waived (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage |
| Emergency care (professional fees) | 100% of allowed amount | 100% of allowed benefit; deductible waived |
| Home Health Services | ||
| Medically necessary services | 100% of allowed amount (40 visits per year maximum for all networks combined; pre-authorization required) | 70% of allowed benefit; deductible applies (40 visits per year maximum for all networks combined; pre-authorization required) |
| Home infusion therapy | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Hospice Care | ||
| Inpatient and home hospice | 100% of allowed amount (pre-authorization required) | 70% of allowed benefit; deductible applies (pre-authorization required) |
| Hospital Care | ||
| Inpatient care including newborn nursery care; NICU (facility fees) | 100% of allowed amount (semi-private, unless private room is medically necessary; pre-authorization required) | $100 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) | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Skilled nursing/rehabilitation facility | 100% of allowed amount (120 days per year maximum for all networks combined; pre-authorization required) | 70% of allowed benefit; deductible applies (120 days per year maximum for all networks combined; pre-authorization required) |
| Short-term acute rehabilitation | 100% of allowed amount (120 days per year maximum for all networks combined; pre-authorization required) | 70% of allowed benefit; deductible applies (120 days per year maximum for all networks combined; pre-authorization required) |
| Observation care (facility fees) | $135 co-pay, then 100% of allowed amount (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage | $135 co-pay, then 100% of allowed benefit; deductible waived (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage |
| Observation care (professional fees) | 100% of allowed amount | 100% of allowed benefit; deductible waived |
| Outpatient surgery & ambulatory surgical center (facility fees) | 100% of allowed amount (includes freestanding surgical centers) | 70% of allowed benefit; deductible applies (includes freestanding surgical centers) |
| Outpatient surgery & ambulatory surgical center (professional fees) | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Hyperbaric Oxygen Therapy | ||
| Medically necessary services | 100% of allowed amount (pre-authorization required) | 70% of allowed benefit; deductible applies (pre-authorization required) |
| Immunizations | ||
| Preventive immunizations for communicable diseases | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Travel immunizations | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Infusion Therapy | ||
| Home infusion therapy | 100% of allowed amount (pre-authorization required) | 70% of allowed benefit; deductible applies (pre-authorization required) |
| Outpatient infusion therapy | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Injections | ||
| Injections | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Materials and serum | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Laboratory | ||
| Laboratory tests including pathology | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Mental Health & Substance Use Disorder Services | ||
| Outpatient mental health care (facility fees) | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Outpatient mental health care (professional fees) | $15 co-pay, then 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Inpatient mental health care (facility fees) | 100% of allowed amount (semi-private, unless private room is medically necessary; pre-authorization required) | $100 co-pay per admission, then 70% of allowed benefit; deductible applies (semi-private, unless private room is medically necessary; pre-authorization required) |
| Inpatient mental health care (professional fees) | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Outpatient substance use disorder care (facility fees) | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Outpatient substance use disorder care (professional fees) | $15 co-pay, then 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Inpatient substance use disorder care (facility fees) | 100% of allowed amount (semi-private, unless private room is medically necessary; pre-authorization required) | $100 co-pay per admission, then 70% of allowed benefit; deductible applies (semi-private, unless private room is medically necessary; pre-authorization required) |
| Inpatient substance use disorder care (professional fees) | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Intensive outpatient program | $15 co-pay, then 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Partial hospital facility services | $15 co-pay, then 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Medication management | $15 co-pay, then 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Mental health testing and procedures | $15 co-pay, then 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Methadone Treatment | ||
| Medically necessary outpatient care | $15 co-pay, then 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Nutritional Counseling | ||
| Medically necessary services | $25 co-pay, then 100% of allowed amount (limited to one initial consultation and one follow-up visit for all networks combined) | 70% of allowed benefit; deductible applies (limited to one initial consultation and one follow-up visit for all networks combined) |
| Office Visits for Treatment of Illness or Injury | ||
| Primary care office visit only (Adult) | $15 co-pay, then 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Primary care office visit (Pediatric: age 19 and under) | $15 co-pay, then 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Primary care office visit only (GYN) | $15 co-pay, then 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Specialty care office visit only (Adult & Pediatric) | $25 co-pay, then 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Treatment and diagnostic services in the office | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Preventive Services | ||
| Preventive exam (PCP, GYN and Well Child care) | $15 co-pay, then 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Diagnostic services for preventive exam | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Routine preventive screenings: mammogram, colonoscopy, PAP test, etc. | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Routine hearing exams | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Private Duty Nursing | ||
| Private Duty Nursing | Not Covered | Not Covered |
| Radiology Procedures | ||
| All imaging studies including X-Ray, ultrasound, MRI, CT and PET scans | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Reproductive Health | ||
| Physician office visits (prenatal care only) | Routine prenatal visits and all other prenatal visits covered at 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Infertility treatment | Not Covered | Not Covered |
| Birthing centers (facility fees) | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Birthing centers (professional fees) | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Inpatient maternity care and delivery; newborn nursery care; NICU (facility fees) | 100% of allowed amount (semi-private, unless private room is medically necessary; pre-authorization required) | $100 co-pay per admission, then 70% of allowed benefit; deductible applies (semi-private, unless private room is medically necessary; pre-authorization required) |
| Inpatient maternity care and delivery; newborn nursery care; NICU (professional fees) | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Interruption of pregnancy | 100% of allowed amount (pre-authorization required; life of mother, rape, or incest only) | 70% of allowed benefit; deductible applies (pre-authorization required; life of mother, rape, or incest only) |
| Female sterilization (professional services for surgery, anesthesia and related pathology) | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Male sterilization (professional services for surgery, anesthesia and related pathology) | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Surgical Procedures | ||
| Surgical treatment for morbid obesity | Not Covered | Not Covered |
| Primary care office surgical procedures | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Specialist care office surgical procedures | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Outpatient surgery (including freestanding surgical centers) (facility fees) | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Outpatient surgery (including freestanding surgical centers) (professional fees) | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Inpatient surgery (facility fees) | 100% of allowed amount (semi-private, unless private room is medically necessary; pre-authorization required) | $100 co-pay per admission, then 70% of allowed benefit; deductible applies (semi-private, unless private room is medically necessary; pre-authorization required) |
| Inpatient surgery (professional fees) | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Therapy | ||
| Habilitative services for children under the age of 19 | Not Covered | Not Covered |
| Physical therapy/occupational therapy medically necessary services | 100% of allowed amount (60 visits per year maximum for all networks combined) | 70% of allowed benefit; deductible applies (60 visits per year maximum for all networks combined) |
| Speech therapy (non-developmental medically necessary services) | 100% of allowed amount (30 visits per year maximum for all networks combined; pre-authorization required) | 70% of allowed benefit; deductible applies (30 visits per year maximum for all networks combined; pre-authorization required) |
| Pulmonary rehabilitation | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Cardiac rehabilitation | 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Vision therapy | Not Covered | Not Covered |
| Urgent Care Center | ||
| Physician visit | $15 co-pay, then 100% of allowed amount | 70% of allowed benefit; deductible applies |
| Diagnostic services and treatment | 100% of allowed amount | 70% of allowed benefit; deductible applies |
Revised
December 1, 2022
Group Number
E0000800, E0000900
Plan Codes
112C0000, 603C0000
