Page 7 - Veritone's EE Guide final

Benefits

Medical Insurance

30 Visits/Year Anthem Blue Cross Anthem Blue Cross
PPO $1,500 Option HSA
Plan Name
Network Network Non-Network Network Non-Network
Health Benefits

Lifetime Maximum Unlimited Unlimited Unlimited Unlimited
Deductible (Annual)
- Individual $1,500 $5,000 $2,700 $5,000
- Family $3,000 $10,000 $5,400 $10,000

Co-Insurance (Plan Pays) 70% 50% 80% 60%
Office Visit Copay
- Primary Care Physician $30 Copay Deductible, 50% Ded, 20% Ded, 40%
- Specialist Office Visit $50 Copay Deductible, 50% Ded, 20% Ded, 40%
Out-of-Pocket Maximum
- Single $5,500 $10,000 $5,500 $10,000
- Family $11,000 $20,000 $11,000 $20,000
Hospitalization
- Inpatient Deductible, 30% $500/Admit, 50% Ded, 20% Ded, 40%
- Outpatient Deductible, 30% Deductible, 50% Ded, 20% Ded, 40%
Lab and X-Ray Deductible, 30% Deductible, 50% Deductible, 20% Deductible, 40%
Emergency Services Ded, 20%
$100 Copay, 30% $100 Copay, 30% Ded, 20%
Urgent Care $30 Copay Deductible, 50% Ded, 20% Ded, 40%
Preventive Care No Change Deductible, 50% 100% Ded, 40%

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

Pharmacy Deductible $0 $0 Health Ded Applies Health Ded Applies
Retail Pharmacy
-Tier 1 (typically generic) $10 Copay Copay + 50% up to 20 % up to $100 Copay + 40% up to
$250 $250
-Tier 2 (typically preferred) $35 Copay Copay + 50% up to 20 % up to $200 Copay + 40% up to
$250 $250
-Tier 3 (typically non- $70 Copay Copay + 50% up to 20 % up to $200 Copay + 40% up to
preferred) $250 $250

- Supply Limit (Up to) 30 Days 30 Days 30 Days
Mail Order Pharmacy
-Tier 1 (typically generic) $20 Copay Not Covered 20 % up to $200 Not Covered
-Tier 2 (typically preferred) $70 Copay Not Covered 20 % up to $400 Not Covered
-Tier 3 (typically non- $140 Copay Not Covered 20 % up to $400 Not Covered
preferred) 90 Days N/A 90 Days N/A
-Supply Limit (Up to)

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