Page 17 - 2022 SoFi - Temp Intern Benefit Guide

HIGH-LEVEL PLAN SUMMARY AND YOUR ASSOCIATED COSTS

UTAH: CIGNA PPO
OTHER STATES: CIGNA OAP
In-Network Out-of-Network
ANNUAL DEDUCTIBLE
Individual $500 $1,500
Family $1,500 $4,500
ANNUAL OUT-OF-POCKET MAXIMUM (INCLUDES DEDUCTIBLE)
Individual $3,000 $9,000
Family $6,000 $18,000
Lifetime Max Unlimited Unlimited
YOU PAY
COINSURANCE / COPAYS
Coinsurance 20%* 40%*
Office Visit $20 copay (Deductible waived) 40%*
Preventive Exams $0 (Deductible waived) 40%*
Routine office visits, immunizations, diagnostic X-ray and lab
Maternity
• Office Visits Plan pays 100% of physician fees 40%*
• All other maternity services 20%* 40%*
Physical Therapy & Chiropractic $20 copay (Deductible waived) 40%*
See plan summaries for limits
Outpatient Standard Lab, X-Ray $0 (Deductible waived) 40%*
MRI, CAT, PETscan
• Physician $20 copay (Deductible waived) 40%*
• Outpatient Facility 20%* 40%*
In-Patient Hospital 20%* 40%*
Outpatient Surgery 20%* 40%*
Urgent Care (Physician Services) $35 copay (Deductible waived) 40%*
Emergency Room 20%* 20%*
Notification is required if confined in a Non-Network Hospital
RETAIL RX (UP TO 30-DAY SUPPLY)

Generic $7 copay
Brand Preferred $30 copay Not covered
Brand Non-Preferred $50 copay
MAIL ORDER RX (UP TO 90-DAY SUPPLY)
Generic $17 copay
Brand Preferred $75 copay Not covered
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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