Page 7 - Razer Benefits Guide 1-18 No CA_PRINT
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MEDICAL INSURANCE






                                                       AETNA                                 AETNA
                                                     HSA PPO                                   PPO
                                            Open Access®                          Open Access®
                                          Managed Choice®                       Managed Choice®
             NETWORK NAME                       POS           Non-Network             POS           Non-Network
             HEALTH BENEFITS
             Lifetime Maximum                          Unlimited                             Unlimited
             Annual Deductible
             •  Individual                     $3,000            $6,000               $300              $600
             •  Family (Ind Protection)    $6,000 ($3,000)   $12,000 ($6,000)      $900 ($300)      $1,800 ($600)
             Coinsurance (You Pay)              10%                50%                 10%               50%
             Physician Office Visit
             •  PCP                        Deductible, 10%   Deductible, 50%       $20 Copay        Deductible, 50%
             •  Specialist                 Deductible, 10%   Deductible, 50%       $40 Copay        Deductible, 50%
             Out-of-Pocket Maximum
             •  Individual                     $5,000            $10,000             $2,500            $5,000
             •  Family (Ind Protection)   $10,000 ($5,000) $20,000 ($10,000)     $5,000 ($2,500)   $10,000 ($5,000)
             Hospitalization
             •  Inpatient                  Deductible, 10%   Deductible, 50%     Deductible, 10%    Deductible, 50%
             •  Outpatient Surgery         Deductible, 10%   Deductible, 50%     Deductible, 10%    Deductible, 50%
             Laboratory & X-Ray
             •  Diagnostic                 Deductible, 10%   Deductible, 50%     Deductible, 10%    Deductible, 50%
             •  Complex                    Deductible, 10%   Deductible, 50%     Deductible, 10%    Deductible, 50%
             Emergency Services                     Deductible, 10%                       $150 Copay, 10%
             Urgent Care                   Deductible, 10%   Deductible, 50%       $35 Copay        Deductible, 50%
             Preventive Care                  No Cost        Deductible, 50%         No Cost        Deductible, 50%
             Chiropractic & Acupuncture    Deductible, 10%   Deductible, 50%       $40 Copay        Deductible, 50%
                                            20 Visits/Year                        20 Visits/Year
             PHARMACY BENEFITS
             Annual Deductible                  Health Deductible Applies                      None
             Retail Pharmacy
             •  Generic                      $10 Copay       $10 Copay + 20%        $10 Copay      $10 Copay + 20%
             •  Brand Formulary              $35 Copay       $35 Copay + 20%       $30 Copay       $30 Copay + 20%
             •  Non-Formulary                $60 Copay       $60 Copay + 20%       $60 Copay       $60 Copay + 20%
             •  Supply Limit                  30 Days            30 Days             30 Days           30 Days
             Mail Order Pharmacy*
             •  Generic                      $20 Copay         Not Covered         $20 Copay         Not Covered
             •  Brand Formulary              $70 Copay         Not Covered         $60 Copay         Not Covered
             •  Non-Formulary                $120 Copay        Not Covered         $120 Copay        Not Covered
             •  Supply Limit                  90 Days              N/A               90 Days             N/A


            *Mail Order Pharmacy is a program where you can order 3 months of your maintenance medication to be delivered
            to your home at a discounted price.

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