Health Plan Definitions



 
 
Changing Your Elections Plan Year
Coordination of Benefits Pre-Existing Condition
Copayments (Copays) and Coinsurance Preferred Provider Organization (PPO)
Deductibles Premium
Dependents Prescription Drugs
In-Network Providers Generic Drugs
Out-of-Network Reasonable and Customary Charges
Out-of-Pocket Maximum Self-Insured or Self-Funded Plan
 


Changing Your Elections

The health plan options you choose on your first day of employment at St. Jude and during the annual enrollment period will be in effect until the end of the current calendar year. If you have a qualifying change in your work or family status during the year, you are permitted to make certain changes to your elections. All changes must be made because of and consistent with your family status change. You must contact Human Resources–Benefits and submit the required documentation within 45 days of the event to ensure coverage. Examples of qualifying work and family status changes are:

There may be other situations in which you are able to make a change in coverage mid-year. Please contact Human Resources–Benefits if you have questions.

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Coordination of Benefits

The St. Jude medical plan has a coordination of benefits (COB) feature that prevents duplication of benefits when you, your spouse or dependent children are covered by another medical and dental plan. Under this feature, the benefits provided by St. Jude will be coordinated with any benefits you or your dependents are eligible to receive under other plans according to certain rules. These rules determine which plan pays benefits first and ensures that the total benefits paid are no more than 100% of the allowable expenses for the claim. These rules generally provide that:

Other COB rules may apply to your situation. Please call Human Resources–Benefits if you have additional questions.

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Copayments (Copays) and Coinsurance

Certain services may require a copay. Copays are required for physician office visits, urgent care (minor medical centers), emergency rooms and prescription drugs. Copays do not count toward your deductible or out-of-pocket maximum. Coinsurance refers to the division of the allowed amount to be paid on a claim (i.e., 70/30 means that 70 percent is to be paid by insurance and 30 percent is to be paid by you).

With both the Select and Choice PPO plans, you will have two different physician office visit copays—one for primary care physicians and a higher one for more expensive specialty physicians. The category of primary care physicians includes the following types of providers:

(Also includes Nurse Practitioner and Physician Assistant)

All other providers, such as cardiologists, dermatologists, etc., are considered specialists.

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Deductibles

Except when a copay is required, you have to meet an annual deductible before the plan starts paying benefits for services. A deductible is the fixed dollar amount you pay for care before the plan begins to pay its share of the eligible expenses. You are responsible for 100% of your medical costs until you reach your annual deductible. In-network and out-of-network deductibles are separate and do not offset each other.

If You Choose to Add Either Spouse and/or Child(ren) Coverage
This level of coverage includes a maximum deductible per family for each calendar year. At least two, up to a maximum of three, covered individuals must fully meet their individual deductibles before the maximum deductible is met for a calendar year.

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Dependents

In addition to covering yourself, you also can choose to cover your eligible dependents (with proper documentation). In general, your eligible dependents include:

If You and Your Spouse Work at St. Jude
If both you and your spouse are employed by St. Jude Children’s Research Hospital, you can select different options in the medical, dental and vision plans. However, you and your spouse cannot be covered as both an employee and a dependent. Only one of you can cover your dependent children.

When you enroll your dependents in the St. Jude benefits program, you may be asked to provide proof that the individuals you wish to cover are eligible dependents. If requested, you will need to provide the following:

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In-Network Providers

CoreSource administers the Select and Choice PPO plans, which use the “GWH-CIGNO PPO” network. It includes local and national providers, including the Methodist/Le Bonheur healthcare systems, as well as St. Francis Hospital (Memphis and Bartlett). To search for an in-network doctor, visit www.mycoresource.com (click “Participants” and then “GWH-Cigna PPO” links).

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Out-of-Network

Services performed by a provider who is not contracted with St. Jude’s preferred provider network.

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Out-of-Pocket Maximum

The out-of-pocket maximum includes the total payments toward eligible expenses that you pay for yourself or for your dependents including deductibles. Once you reach this limit, the plan will pay 100% of reasonable and customary charges for covered health services received during the remainder of that calendar year. Some out-of-pocket costs (e.g., emergency room copays, office visit copays, pharmacy copays) do not count toward the out-of-pocket maximums.

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Plan Year

January 1 through December 31 for medical, dental and vision plans, as well as for the Flexible Spending Account plans.

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Pre-Existing Condition

A condition diagnosed and/or treated prior to the effective date of coverage or one for which a prudent person would have been treated.

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Preferred Provider Organization (PPO)

A plan that allows a member to choose either a provider of their choice or a provider contracted with the network. Choosing an in-network provider will result in a higher percentage of the cost of services being covered.

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Premium

The amount you and your employer pay for insurance coverage.

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Prescription Drugs

Any drug or medication that requires a physician order.

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Generic Drug

A generic drug is one approved by the U.S. Food and Drug Administration (FDA) that ischemically identical to its brand-name equivalent. To win FDA approval, the generic drugmust contain the same amounts of the same active ingredients as its brand-name equivalent.A generic drug typically is less expensive and is sold under a generic name for that drug(usually its chemical name). Because generic drugs are less expensive than their brand-nameequivalent, your co-payment usually is less, as well.

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Reasonable and Customary Charges

The prevailing charge made by physicians, dentists, or other service providers for a similar procedure in a particular geographic area.

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Self-Insured or Self-Funded Plan

The St. Jude medical program is self-insured (also called “self-funded”), meaning that the cost of each claim is paid directly by St. Jude—not by an insurance company. By self-funding, St. Jude assumes the risk, but is in turn able to adjust contribution rates and benefits according to plan usage. So, the less money spent on benefit claims, the more money available so that cost increases are kept to a minimum for our employees. St. Jude contracts with a third party administrator to provide administrative services.

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