Medical Coverage Chart

This chart provides a few examples of your payment responsibility under each medical option. Consult the Summary Plan Descriptions (SPD) for coverage details.

 

Choice Plus

Choice

BJC Facility Network

Cigna OAP Network

Non-Network

BJC Facility Network

Cigna Network

Non-Network

Annual Deductible – Per Individual (3x Family)

$200

$600

$3,000

$600

$2,500

$5,000

Annual Out-of-Pocket Maximum

 
  • Per Individual

$1,200

$4,600

Unlimted

$4,000

$4.600

Unlimted

  • Per Individual
       

Urgent Care

$50

$60

Emergency Room

$150

$200

Wellness and Preventive Care

$0

$0

50%

$0

$0

75%

Cigna Telehealth

N/A*

$25

Not Covered

N/A*

$25

Not Covered

Diagnostic/Non-Preventive Office Visit

           
  • Primary Care Physcian (PCP)

N/A*

$25

50%*

N/A*

$40

75%

  • Specialists

N/A*

$50

50%

N/A*

$60

75%

Outpatient Short-Term Therapy

$20

$35

50%

$30

$50

75%

Outpatient Surgery

0%

40%

41,500
& 50%

12%

60%

$3,000
& 75%

Hospital Services

           
  • Inpatient Technical Charges**

0%

40%

$2,500
& 50%

15%

60%

$5,000
& 75%

  • Outpatient Technical Charges**

0%

40%

50%

15%

60%

$5,000
& 75%

  • Inpatient Professional Charges***

N/A*

20%

50%

N/A*

40%

75%

  • Outpatient Professional Charges***

N/A *

20%

50%

N/A*

40%

75%


* The BJC Facility Network does not include physicians; BJC Medical Group, Memorial Medical Group and Washington University physicians
are included in the Cigna OAP Network.

** Billed by Facility. Technical charges for the tools and services that a professional uses to provide health care services, such as equipment,
supplies, operating room time, radiology, general nursing care, etc.

*** Billed by Physician. Professional charges for a physician or other licensed health care professional’s time and expertise to provide health
care services to an individual.

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