California Company
Quote Id: 1814-6241

Anthem Platinum PPO 200/10%/3000
Employee NameAgeTierDep CountAreaEEDepTotal
Employee 00135ES1CA03640.87640.871,281.74
Employee 00245EC1CA03757.29333.021,090.31
Employee 00325EE0CA03526.540.00526.54
Employee 00455ES1CA031,169.501,023.712,193.21
Employee 00565EE0CA031,573.320.001,573.32
Total: 5
Rate Totals:$4,667.52$1,997.60$6,665.12


BenefitPPOOut of Network
DEDUCTIBLE
     Individual$200$600
     Family$600 (embedded)$1,200 (embedded)
OUT-OF-POCKET MAX
     Individual$3,000 (includes ded.)$6,000 (includes ded.)
     Family$6,000 (embedded, includes ded.)$12,000 (embedded, includes ded.)
PHYSICIAN SERVICES
     Office Visits$10/$30 copay/visit (ded. waived)50% of allowed amount after ded.
     Preventive Care$0 (ded. waived)50% of allowed amount after ded.
     Diagnostic Lab/X-Ray10% after ded.50% of allowed amount after ded.
     Imaging (CT/PET scans, MRIs)10% after ded.50% of allowed amount after ded. ($800 max benefit/test)
     Rehabilitation/Habilitation (PT/OT/ST)$10 copay/visit (ded. waived)50% of allowed amount after ded.
     Chiropractic Care$10 copay/visit (ded. waived, 20 visits/cal. yr.)50% of allowed amount after ded. ($25 max benefit/visit, limit combined w/PPO)
PRESCRIPTION DRUGS
     Tier 1 (Generic Formulary)$10 (30 day supply; Select Rx)50% of Drug Limited Fee Schedule (30 day supply)
     Tier 2 (Preferred Brand Formulary)$35 (30 day supply; Select Rx)50% of Drug Limited Fee Schedule (30 day supply)
     Tier 3 (Non-Preferred Brand Formulary)$70 (30 day supply; Select Rx)50% of Drug Limited Fee Schedule (30 day supply)
     Tier 4 (Specialty Drugs)25% up to $250 max (30 day supply; Select Rx)50% of Drug Limited Fee Schedule (30 day supply)
     Mail Order2.5x Retail [Tier 1]; 3.0x Retail [Tier 2 & 3] (90 day supply; Select Rx)Not Covered
HOSPITAL FACILITY SERVICES
     Inpatient Hospital Services10% after ded.50% of allowed amount after ded. ($650 max benefit/day)
     Outpatient Surgery in a Hospital10% after ded.50% of allowed amount after ded. ($380 max benefit/admit)
     Ambulatory Surgical Center10% after ded.50% of allowed amount after ded. ($380 max benefit/admit)
EMERGENCY SERVICES
     Emergency Room$200 copay + 10% after ded. (copay waived if admitted)$200 copay + 10% after ded. (copay waived if admitted)
     Emergency Transport/Ambulance10% after ded.10% after ded.
     Urgent Care$100 copay/visit (ded. waived)50% of allowed amount after ded.
MENTAL HEALTH/SUBSTANCE USE DISORDER
     Outpatient Services$10 copay/visit (ded. waived)50% of allowed amount after ded.
     Inpatient Services10% after ded.50% of allowed amount after ded. ($650 max benefit/day)
MATERNITY
     Prenatal and Postnatal CarePrenatal: $0; Postnatal: 10% after ded.50% of allowed amount after ded.
     Delivery and All Inpatient Services10% after ded.50% of allowed amount after ded. ($650 max benefit/day)
PEDIATRIC SERVICES (UP TO AGE 19)
     Eye Exam$0 (ded. waived, 1 exam/cal. yr.)All charges except $30 reimbursement
     Glasses$0 (ded. waived, 1 pair/cal. yr.)All charges except specified reimbursement (see EOC for details)
     Dental Check-upNo ChargeNo Charge