Page 6 - 2022 New Relic Guide

Your Health
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KAISER HMO PLANS

Below are side-by-side comparisons of your available Kaiser medical plans. Please keep in mind that this list is just a summary. For more
complete information, visit Nerd Life.

KAISER HMO (OR ONLY) KAISER HMO (CA ONLY)
ANNUAL DEDUCTIBLE
Individual
Individual in a Family None None

Family
ANNUAL OUT-OF-POCKET MAXIMUM
Individual $1,500 $1,500
Family $3,000 $3,000

OFFICE VISITS / HOSPITAL
Office Visit, Primary/ $10 per visit $10 per visit
Specialist
Preventive Care 100% covered 100% covered
Well Child Exams/ 100% covered 100% covered
Immunizations
Urgent Care $10 per visit $10 per visit
Emergency Room Visit $100 per visit (waived if admitted) $100 per visit (waived if admitted)

Ambulance $50 per trip $50 per trip
Inpatient Services $100 per admit $100 per admit
Outpatient Services $10 per procedure $10 per procedure

PLEASE NOTE: The benefits illustrated in this booklet are meant to serve as a summary of the benefits available under each carrier's plan. Reference carrier plan summary for full benefit
information. Should any discrepancies arise, the carrier's documents supersede these illustrations.

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2022 US Benefits Guide