Medical Schedule of Benefits
Johns Hopkins Student Health Program
Effective July 1, 2014
2014
Option 1
EHP Network Provider
All Services Subject to Deductible*
2014
Option 2
Out of Network Provider
All Services Subject to Deductible*
Individual
$100
$100
Family
$300
$300
Individual
$3000 Medical
$3600 Pharmacy
$3000 Medical
No maximum on pharmacy costs
Family
$9000 Medical
$4200 Pharmacy
$9000 Medical
No maximum on pharmacy costs
2014
Option 1
EHP Network Provider
All Services Subject to Deductible*
2014
Option 2
Out of Network Provider
All Services Subject to Deductible*
($300 plan maximum)
(pre-authorization required)
80%
70% of R&C
Services & Supplies
Plan Year Deductible
(all options combined)
Co-Insurance Out of
Pocket Maximum
Per Plan Year
(all options combined)
Services & Supplies (In Alphabetical Order)
Acupuncture
Allergy Tests &
Procedures
Ambulance
Transportation
Allergy Tests
90%
90% of R&C
Desensitization Materials and Serum
80%
80% of R&C
Medically Necessary Transport
80%
80% of R&C
Physician Visit
100%
80% of R&C
Physician Materials
80%
80% of R&C
Restricted to Initial Exam, X-Rays, and Spinal Manipulations
($1,000 plan maximum)
80%
80% of R&C
Breast Pumps and Related Supplies
100% (deductible waived)
70% of R&C (1)
Contraceptive Devices
100% (deductible waived)
70% of R&C
Medically Necessary Equipment
(pre-authorization required)
80%
80% of R&C
Medically Necessary Hearing Aids for dependent children up to age 26
(limited to every 36 months for one hearing aid for each hearing impaired ear)4
80%
80% of R&C
Medically Necessary Prosthetic Appliances
(pre-authorization required)
80%
80% of R&C
Emergency Services
Emergency Care (facility and professional fees)
(i.e., the onset of a sudden and serious condition requiring immediate care)
100% for services within 72 hours after
onset of emergency, then 80%
100% of R&C for services within 72 hours
after onset of emergency,
then 80% of R&C
Home Health Services
(pre-authorization required)
100% for first 90 visits per plan year,
then 80% (1)
90% of R&C for first 90 visits per plan
year, then 80% of R&C (1)
Hospice Care
Inpatient and Home Hospice
100% (1)
100% of R&C (1)
Hospital Care
Inpatient Care, including Newborn/NICU
(semi-private, unless private room is Medically Necessary)
100% for first 30 days, then 80% (1)
100% of R&C for first 30 days,
then 80% of R&C (1)
Chemotherapy/
Radiation Therapy
Chiropractic Care
Durable Medical
Equipment
Revised: 8/8/2014
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Medical Schedule of Benefits
Johns Hopkins Student Health Program
Effective July 1, 2014
2014
Option 1
EHP Network Provider
All Services Subject to Deductible*
2014
Option 2
Out of Network Provider
All Services Subject to Deductible*
Inpatient Physician Services
(excluding surgical services)
80% (1)
80% of R&C (1)
Other Inpatient Services
100% for first 30 days, then 80% (1)
100% of R&C for first 30 days, then 80%
of R&C (1)
Skilled Nursing/Rehabilitation Facility
100% for first 30 days, then 80% (1)
100% of R&C for first 30 days, then 80%
of R&C (1)
Outpatient Services
(including outpatient testing prior to outpatient surgery)
90%
90% of R&C
Outpatient Surgery Facility Charges
(including freestanding surgical centers)
90% (1)
90% of R&C (1)
Laboratory
Laboratory Tests, Imaging Exams, X-Ray Exams, and Ultrasound
90%
70% of R&C
Medical Supplies
Disposable Supplies (e.g. ostomy bags, diabetic supplies, syringes)
Diabetic supplies may be obtained through any participating pharmacy
80%
80% of R&C (1)
Professional Fees for Outpatient Mental Health Care
90%
90% of R&C
Services & Supplies
Hospital Care
(continued)
Mental Health &
Substance Abuse
Services
Nutritional Counseling
Office Visits for Treatment
of Illness or Injury
Preventive Services
Revised: 8/8/2014
Facility Fees for Outpatient Mental Health Care
90%
90% of R&C
Professional Fees for Inpatient Mental Health Care
80% (1)
80% of R&C (1)
Facility Fees for Inpatient Mental Health Care
100% for first 30 days, then 80% (1)
100% of R&C for first 30 days,
then 80% of R&C (1)
Professional Fees for Inpatient Alcohol and Substance Abuse Care
80% (1)
80% of R&C (1)
Facility Fees for Inpatient Alcohol and Substance Abuse Care
100% for first 30 days, then 80% (1)
100% of R&C for first 30 days,
then 80% of R&C (1)
Professional Fees for Outpatient Alcohol and Substance Abuse Care
100%
80% of R&C
Facility Fees for Outpatient Alcohol and Substance Abuse Care
90%
90% of R&C
Limited to one initial consultation and one follow-up visit
(with additional visits if pre-authorized)
90%
70% of R&C
Primary Care Office Visit (over 19 years of age)
80%
70% of R&C
Specialty Care Office Visit (over 19 years of age)
90%
70% of R&C
Pediatric Care Office Visit (under 19 years of age)
100%
90% of R&C
Pediatric Specialty Care Office Visit (under 19 years of age)
90%
70% of R&C
Podiatry Care Office Visit
90%
70% of R&C
Adult General Physical Exam
100% (deductible waived)
70% of R&C
Adult Immunizations and Inoculations
(Gardasil covered for FDA approved age range of 9-26 years of age)
(immunizations related to travel are not covered)
100% (deductible waived)
70% of R&C
Annual GYN Exam
100% (deductible waived)
70% of R&C
Annual Pap (pathology)
100% (deductible waived)
70% of R&C
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Medical Schedule of Benefits
Johns Hopkins Student Health Program
Effective July 1, 2014
Services & Supplies
Preventive Services
(continued)
Physical/
Occupational Therapy
Colonoscopy (screening)
100% (deductible waived)
70% of R&C
100% (deductible waived)
70% of R&C
Mammograms (screening)
100% (deductible waived)
90% of R&C
Well Child Care
(immunizations related to travel are not covered)
100% (deductible waived)
90% of R&C
Medically Necessary Services
(excludes maintenance therapy)
80%
80% of R&C
Physician Office Visits (prenatal care only)
90%
70% of R&C
(1)
90% of R&C (1)
90% (1)
70% of R&C (1)
Newborn Care (initial and discharge visits only)
90%
(1)
90% of R&C (1)
Newborn Care (all other inpatient visits)
80%
(1)
80% of R&C (1)
Charges for Delivery and Related Anesthesia
Speech Therapy
Surgical Procedures
Urgent Care Center
Revised: 8/8/2014
2014
Option 2
Out of Network Provider
All Services Subject to Deductible*
Diagnostic Services for Physical Exam
Birthing Centers (licensed facility)
Reproductive Health
2014
Option 1
EHP Network Provider
All Services Subject to Deductible*
90%
Sterilization (female voluntary)
(professional services for surgery, anesthesia, and related pathology)
100% (deductible waived)
80% of R&C (1)
Sterilization (male voluntary)
80% (1)
80% of R&C (1)
Non-Developmental Medically Necessary Services
(pre-authorization required)
80% (1) (3)
80% of R&C (1) (3)
Professional Services for Inpatient and Outpatient Surgery
80% (1)
70% of R&C (1)
Professional services for Medically Necessary Reconstructive and/or Surgically Implanted
Prosthetic Devices
(pre-authorization required)
80% (1)
70% of R&C (1)
Gastric Bypass Surgery
(pre-authorization required) (1)
80% at JHH institutions only (2)
Available under Option 1 only
Physician Visit
100%
80% of R&C
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Medical Schedule of Benefits
Johns Hopkins Student Health Program
Effective July 1, 2014
In Network Retail Pharmacy
(34-day supply)
Prescription Drugs
Oral Contraceptives
All Other Prescriptions
Mail Order
(90-day supply)
Generic
$0
$0
$0
Preferred
$20
$60
$40
Non-Preferred
$30
$90
$60
Generic
$10
$30
$20
Preferred
$20
$60
$40
Non-Preferred
$30
$90
$60
* Deductible applies except for specific benefits where deductible waived is noted.
(1) Failure to obtain pre-authorization may result in a penalty or possible denial of benefits.
(2) Surgery must be pre-certified by the Care Management Program and all services must be provided at
Johns Hopkins institutions.You must first participate for at least six months in a medically supervised
weight management program that is approved and monitored by the Care Management Program.
(3) Covered benefits only include therapy aimed at restoring the level of speech the individual had attained
before the onset of a condition (i.e., before an illness or injury). Speech therapy for developmental
disorders, such as stuttering, articulation disorders, tongue thrust, lisping, etc. is not covered.
(4) Services must be authorized by Care Management and prescribed, fitted and dispensed by licensed
audiologist; replacement aids once every 36 months.
Revised: 8/8/2014
In Network Retail Pharmacy
(90-day supply)
“R&C” (Reasonable and Customary Charge) – This is the usual fee charged by similar providers for the
same services or supplies in the same geographic area. Johns Hopkins Employer Health Programs (EHP)
determines what is a Reasonable and Customary Charge. EHP Network providers (Option 1) will not
charge more than the Reasonable and Customary Charge, but non-network providers can charge more.
For more information look under the heading “Payment Terms You Should Know” in your Summary Plan
Description (SPD) or contact your Human Resources Benefits Service Center.You are responsible for any
charges above R&C.
All benefits are subject to medical necessity.
This is not a complete description of benefits. For more information, please refer to the Summary Plan
Description (SPD).
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