Page 11 - Veritone EE California and Colorado Benefit Guide_2019

Option 4 3 Option 5 Option 6
Anthem Blue Cross Anthem Blue Cross Anthem Blue Cross
Plan Name PPO $500 PPO $1,500 HSA PPO

Prudent Buyer Prudent Buyer Prudent Buyer
Network Name Non-Network Non-Network Non-Network
PPO or National or National

Health Benefits
Lifetime Maximum Benefit Unlimited Unlimited Unlimited

Calendar Year Deductible
- Individual $500 $1,000 $1,500 $5,000 $2,700 $5,000
- Family $1,000 $2,000 $3,000 $10,000 $5,400 $10,000

Out-of-Pocket Maximum
- Individual $3,500 $6,500 $5,500 $10,000 $5,500 $10,000
- Family $7,000 $13,000 $11,000 $20,000 $11,000 $20,000
Coinsurance (Plan Pays) 80% 60% 70% 50% 80% 60%

Office Visit Copay
- Preventive Care No Charge Deductible, 40% No Charge Deductible, 50% Deductible, 20% Deductible, 40%
- Primary Care Physician $20 Copay Deductible, 40% $30 Copay Deductible, 50% Deductible, 20% Deductible, 40%
- Specialist $40 Copay Deductible, 40% $50 Copay Deductible, 50% Deductible, 20% Deductible, 40%
- Urgent Care $20 Copay Deductible, 40% $30 Copay Deductible, 50% Deductible, 20% Deductible, 40%
- Telemedicine $10 Copay N/A $10 Copay N/A Deductible, 20% N/A

Hospitalization
- Inpatient Deductible, 20% Deductible, 40% Deductible, 30% $500/Admit, 50% Deductible, 20% Deductible, 40%
- Outpatient Surgery Deductible, 20% Deductible, 40% Deductible, 30% Deductible, 50% Deductible, 20% Deductible, 40%

Lab and X-Ray
- Diagnostic Deductible, 20% Deductible, 40% Deductible, 30% Deductible, 50% Deductible, 20% Deductible, 40%
- Complex Deductible, 20% Deductible, 40% Deductible, 30% Deductible, 50% Deductible, 20% Deductible, 40%
Emergency Services $100 Copay, 20% $100 Copay, 30% Deductible, 20%

Chiropractic $20 Copay Deductible, 40% $30 Copay Deductible, 50% Deductible, 20% Deductible, 40%
Max 30 Visits/Year Max 30 Visits/Year Max 30 Visits/Year