Page 3 - Razer Benefits At A Glance Guide 1-19

MEDICAL KAISER HMO (CA ONLY) AETNA HMO (CA ONLY)
Benefits Network Network
Annual Deductible $0 $0
Physician Office Visit
• Preventive Care No Cost No Cost
• PCP / Specialist $20 Copay $20 / $25 Copay
• Urgent Care $20 Copay $35 Copay
• Chiro & Acupuncture $10 Copay $15 Copay
Out-of-Pocket Maximum $1,500/$3,000 $1,500/$3,000
Hospitalization $500 Copay $500 Copay
Laboratory & X-Ray $10 Copay ($50 Copay Complex) No Cost ($100 Copay Complex)
Emergency Services $100 Copay $100 Copay
Retail Prescription Drugs
• Pharmacy Deductible $0 $0
• Generic $15 Copay $15 Copay
• Brand Formulary $35 Copay $25 Copay
• Non-Formulary N/A $40 Copay
Employee Contributions Per Pay Period Per Pay Period
• Employee Only $20.74 $25.64
• Employee + Spouse $95.40 $114.12
• Employee + Child(ren) $82.95 $98.73
• Employee + Family $145.17 $187.21

MEDICAL AETNA HSA PPO AETNA PPO
Benefits Network Non-Network Network Non-Network
Annual Deductible $3,000/$6,000 $6,000/$12,000 $300/$900 $600/$1,800
Physician Office Visit
• Preventive Care No Cost Deductible, 50% No Cost Deductible, 50%
• PCP / Specialist Deductible, 10% Deductible, 50% $20 / $40 Copay Deductible, 50%
• Urgent Care Deductible, 10% Deductible, 50% $35 Copay Deductible, 50%
• Chiro & Acupuncture Deductible, 10% Deductible, 50% $40 Copay Deductible, 50%
Out-of-Pocket Maximum $5,000/$10,000 $10,000/$20,000 $2,500/$5,000 $5,000/$10,000
Hospitalization Deductible, 10% Deductible, 50% Deductible, 10% Deductible, 50%
Laboratory & X-Ray Deductible, 10% Deductible, 50% Deductible, 10% Deductible, 50%
Emergency Services Deductible, 10% $150 Copay, 10%
Retail Prescription Drugs
• Pharmacy Deductible Health Deductible Health Deductible $0 $0
• Generic $10 Copay $10 Copay + 20% $10 Copay $10 Copay + 20%
• Brand Formulary $30 Copay $30 Copay + 20% $30 Copay $30 Copay + 20%
• Non-Formulary $60 Copay $60 Copay + 20% $60 Copay $60 Copay + 20%
Employee Contributions Per Pay Period Razer HSA Per Pay Period
• Employee Only $19.83 Contribution per $28.28
• Employee + Spouse $88.25 Pay Period $125.85
• Employee + Child(ren) $76.35 $38.46 Employee $108.88
• Employee + Family $144.77 $76.92 Family $206.46

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