Page 13 - Veritone EE California and Colorado Benefit Guide_2019

Veritone’s medical plans include prescription drug coverage for you and your covered
Retail Pharmacy Pharmacy Tips

Use a retail pharmacy to fill prescriptions for acute conditions (conditions that Use generic and over the counter drugs when available. The best
do not require the medication to be taken on a regular basis). At a participating way to save on prescriptions is to use generic or over the counter
pharmacy, you will receive up to a 30 day supply of your prescriptions. medications as opposed to brand name drugs. Generic drugs must use
Mail Order Pharmacy – Maintenance Medication the same active ingredients as the brand name version of the drug. A
You could pay less for the same medication when you use the mail order generic drug must also meet the same quality and safety standards.
pharmacy. The mail order pharmacy is a fast, easy and convenient way to save Use the mail order benefit for maintenance medications To save
time and money on your maintenance medications (drugs that you need to take money and time, consider using the mail order pharmacy to fill your
regularly). You can order additional supplies of medication at a discount. See maintenance medications.
below for details!

Option 1 1 Option 2 Option 3 Option 4 Option 5 Option 6

Anthem Anthem Anthem
CA Kaiser Anthem CO Kaiser Blue Cross Blue Cross Blue Cross
Plan Name HMO HMO HMO PPO $500 PPO $1,500 HSA PPO

Deductible $0 $0 $0 $0 $0 $0 $0 Health Deductible Applies

Retail Pharmacy
Tier 1 $10 Copay $10 Copay $10 Copay $10 Copay 50% $10 Copay 50% 20% Max $100 40%
Tier 2 $35 Copay $25 Copay $30 Copay $25 Copay Max $250/Rx $35 Copay Max $250/Rx 20% Max $200 Max $250/Rx
Tier 3 N/A $50 Copay $50 Copay $50 Copay $70 Copay 20% Max $200
Supply Limit 30 Days 30 Days 30 Days 30 Days 30 Days 30 Days 30 Days 30 Days 30 Days

Mail Order Copay
Tier 1 $20 Copay $20 Copay $20 Copay $20 Copay Not Covered $20 Copay Not Covered 20% Max $200 Not Covered
Tier 2 $70 Copay $50 Copay $60 Copay $50 Copay Not Covered $70 Copay Not Covered 20% Max $400 Not Covered
Tier 3 N/A $100 Copay $100 Copay $100 Copay Not Covered $140 Copay Not Covered 20% Max $400 Not Covered
Supply Limit 100 Days 90 Days 90 Days 90 Days N/A 90 Days N/A 90 Days N/A