California Company
Quote Id: 1814-6241

Smile (SM) Plus Gold 50/1500/Ortho/U85
Employee NameAgeTierDep CountAreaEEDepTotal
Employee 00135ES1CA0364.1065.00129.10
Employee 002451C1CA0364.1098.80162.90
Employee 00325EE0CA0364.100.0064.10
Employee 00455ES1CA0364.1065.00129.10
Employee 00565EE0CA0364.100.0064.10
Total: 5
Rate Totals:$320.50$228.80$549.30


BenefitPPOOut of Network
DEDUCTIBLE
     Individual$50combined w/PPO
     Family3 members/familycombined w/PPO
     Waived for PreventiveYesYes
ELIGIBILITY
     Group Size Dental Services1-100 enrolled1-100 enrolled
     Group Size Ortho1-100 enrolled1-100 enrolled
WAITING PERIODS
     MajorNoneNone
     Waived for major if there was prior group coverage?Not ApplicableNot Applicable
     OrthoNoneNone
DENTAL SERVICES
     Preventive CareNo Charge (ded. waived)20% (ded. Waived) based on 85th percentile of UCR.
     Basic Services20% after ded.30% of UCR, 85th % after ded.
     Major Services50% after ded.50% after ded. based on 85th percentile of UCR.
     Periodontal SurgeryMajorMajor
     Endodontic SurgeryMajorMajor
ORTHO
     Co-pay50% (ded. waived)50% (ded. waived) based on 85th percentile of UCR.
     OrthodonticsChild and AdultChild and Adult
     TakeoverYesYes
BENEFIT MAXIMUMS
     Annual Benefit Max$1,500$1,000 (combined w/PPO)
     Lifetime - Ortho$1,000/cal. yr.combined w/PPO