Page 20 - 2022 SoFi - August Open Enrollment

HIGH-LEVEL PLAN SUMMARY AND YOUR ASSOCIATED COSTS

CIGNA OAPIN
In-Network Only
ANNUAL DEDUCTIBLE
Individual $250
Family $500
ANNUAL OUT-OF-POCKET MAXIMUM (INCLUDES DEDUCTIBLE)
Individual $2,250
Family $4,500
Lifetime Max Unlimited
YOU PAY
COINSURANCE/COPAYS
Coinsurance 10%*
Office Visit $15 copay (Deductible waived)
Preventive Exams $0 (Deductible waived)
Routine office visits, immunizations, diagnostic X-ray and lab
Maternity
• Office Visits Plan pays 100% of global physician fees
• All other maternity services 10%*
Fertility $15 copay (deductible waived)/10%*
Physician/Facility $20,000 maximum per lifetime
Physical Therapy & Chiropractic $15 copay (Deductible waived)
See plan summaries for limits
Outpatient Standard Lab, X-Ray $0 (Deductible waived)
MRI, CAT, PETscan
• Physician $0 (Deductible waived)
• Outpatient Facility 10%*
In-Patient Hospital 10%*
Outpatient Surgery 10%*
Urgent Care (Physician Services) $50 copay (Deductible waived)
Emergency Room 10%*
Notification is required if confined in a Non-Network Hospital
RETAIL RX (UP TO 30-DAY SUPPLY)
Generic $15 copay
Brand Preferred $35 copay
Brand Non-Preferred $50 copay
MAIL ORDER RX (UP TO 90-DAY SUPPLY)

Generic $37 copay
Brand Preferred $87 copay
Brand Non-Preferred $125 copay
* After deductible
Note: A more detailed summary of coverage is available in the Workday Benefits Mall.
This is a partial summary of benefits only. The Summary Plan Description (SPD) contains a complete detail of benefits, limitations and exclusion.
The SPD also describes grievance procedures for disputes. We strongly encourage you to review the SPD before applying for coverage.
You may obtain a copy from the People Team.

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