California Company
Quote Id: 1814-6241

Kaiser Silver 70 HMO 1500/45 w/o Child Dental
Employee NameAgeTierDep CountAreaEEDepTotal
Employee 00135ES1CA03326.89326.89653.78
Employee 00245EC1CA03386.27169.86556.13
Employee 00325EE0CA03268.570.00268.57
Employee 00455ES1CA03596.53522.161,118.69
Employee 00565EE0CA03802.500.00802.50
Total: 5
Rate Totals:$2,380.76$1,018.91$3,399.67


BenefitHMO
DEDUCTIBLE
     Individual$1,500
     Family$3,000 (embedded)
OUT-OF-POCKET MAX
     Individual$6,500 (includes ded.)
     Family$13,000 (embedded, includes ded.)
PHYSICIAN SERVICES
     Office Visits$45/$70 (ded. waived)
     Preventive Care$0 (ded. waived)
     Diagnostic Lab/X-RayLab: $35; X-Ray: $65 (ded. waived)
     Imaging (CT/PET scans, MRIs)$250 (ded. waived)
     Rehabilitation/Habilitation (PT/OT/ST)$45 (ded. waived)
     Chiropractic CareNot Covered
PRESCRIPTION DRUGS
     Tier 1 (Generic Formulary)$15 (30 day supply)
     Tier 2 (Preferred Brand Formulary)$55 (30 day supply)
     Tier 3 (Non-Preferred Brand Formulary)$55 (30 day supply)
     Tier 4 (Specialty Drugs)20% (up to 30 day supply)
     Mail Order2x retail (up to 100 day supply)
HOSPITAL FACILITY SERVICES
     Inpatient Hospital Services20% after ded.
     Outpatient Surgery in a Hospital20%/procedure (ded. waived)
     Ambulatory Surgical Center20%/procedure (ded. waived)
EMERGENCY SERVICES
     Emergency Room$300 after ded. (copay waived if admitted)
     Emergency Transport/Ambulance$250 after ded./trip
     Urgent Care$45 (ded. waived)
MENTAL HEALTH/SUBSTANCE USE DISORDER
     Outpatient Services$45 (ded. waived)
     Inpatient Services20% after ded.
MATERNITY
     Prenatal and Postnatal Care$0 (ded. waived, scheduled prenatal and first postnatal)
     Delivery and All Inpatient Services20% after ded.
PEDIATRIC SERVICES (UP TO AGE 19)
     Eye ExamKaiser Permanente: $0 (ded. waived, 1 exam/cal. yr.)
     GlassesKaiser Permanente: $0 (ded. waived, 1 pair of glasses/cal. yr., limitations apply)
     Dental Check-upNot Covered