Page 7 - 2022 New Relic Guide
P. 7
Your Health
Summary of Your Your Health Pre-Tax Spending Life/AD&D Where to Find
How to Get Started Dental & Vision 401(k) Additional Benefits
Contributions BenefitsBenefits Accounts Disability Support
KAISER HMO PLANS
KAISER HMO (OR ONLY) KAISER HMO (CA ONLY)
MENTAL HEALTH / SUBSTANCE ABUSE
Outpatient $10 per visit $10 per visit
Inpatient $100 per admission $100 per admission
SUBSTANCE ABUSE
Outpatient $10 per visit $10 per visit
Inpatient $100 per admission $100 per admission
PHARMACY
RETAIL (UP TO 30-DAY SUPPLY)
Generic $10 copay $10 copay
Brand Name $20 copay $30 copay
MAIL ORDER (UP TO 100-DAY SUPPLY)
Generic $20 copay $20 copay
Brand Name $40 copay $60 copay
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.
Kaiser Nerd Life
7
2022 US Benefits Guide
