Page 11 - Veritone EE OOS Benefit Guide_2020
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MEDICAL PLAN HIGHLIGHTS -




                                                3                     Option 2                                             Option 3
                                                                Anthem Blue Cross                                     Anthem Blue Cross
       Plan Name                                                    PPO  $1,500                                            HSA PPO

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

       Health Benefits
       Lifetime Maximum Benefit                                       Unlimited                                             Unlimited

       Calendar Year Deductible
        - Individual                                       $1,500                   $5,000                       $2,800                   $5,000
        - Family                                           $3,000                  $10,000                      $5,400                   $10,000

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

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

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

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

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


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