Page 6 - Razer Benefits Guide 1-18 TEXAS

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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