Suburban DPC Plan — 2023
Medical Services and Supplies
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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; 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) | 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% 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 | 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%, 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 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) | 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 — Dependent without DPC as PCP) | 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) (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%, deductible applies | 80%, 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%, deductible applies | 80%, 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%, 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 9, 2024
Group Number
E0007000
Plan Codes
Under $50K: JD1C0000; $50K to $120K: JD3C0000; $120K and over: JD5C0000
