Page 8 - 2022 New Relic Guide

Summary of Your Your Health Pre-Tax Spending Life/AD&D Where to Find
Your Health
How to Get Started Dental & Vision 401(k) Additional Benefits
Contributions BenefitsBenefits Accounts Disability Support

CIGNA OAP PLANS

CIGNA PPO OAP $250/$500 CIGNA HDHP OAP $1,800/$3,600
In-Network Out-of-Network In-Network Out-of-Network
ANNUAL DEDUCTIBLE
Individual $250 $500 $1,800 $3,600

Individual in a Family N/A N/A $2,800 $7,200
Family $500 $1,000 $3,600 $7,200
ANNUAL OUT-OF-POCKET MAXIMUM
Individual $2,400 $6,000 $4,000 $8,000
Family $4,800 $12,000 $6,550 $16,000

OFFICE VISITS / HOSPITAL
Office Visit, Primary/Specialist $20 per visit 30%* 10%* 30%*
Preventive Care 100% covered Not covered 100% covered Not covered
Well Child Exams/Immunizations 100% covered Not covered 100% covered Not covered
Urgent Care $50 copay 30%* 10%* 30%*

Emergency Room Visit $100 per visit + 10%* $100 per visit + 10%* 10%* 10%*
Ambulance 10%* 10%* 10%* 10%*
$100 per admit + $100 per visit
Inpatient Services 30%* 10%* 30%*
+ 10%*
Outpatient Services 10%* 30%* 10%* 30%*

* Services indicated are subject to the annual deductible before benefits are paid.

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.

Cigna Nerd Life

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2022 US Benefits Guide