California Company
Quote Id: 1814-6241

Select Plus 30%/2000/30% AE-JD (Silver)
Employee NameAgeTierDep CountAreaEEDepTotal
Employee 00135ES1CA03410.02410.02820.04
Employee 00245EC1CA03484.51213.06697.57
Employee 00325EE0CA03336.870.00336.87
Employee 00455ES1CA03748.23654.951,403.18
Employee 00565EE0CA031,006.590.001,006.59
Total: 5
Rate Totals:$2,986.22$1,278.03$4,264.25


BenefitPPOOut of Network
DEDUCTIBLE
     Individual$2,000$4,000
     Family$4,000 (embedded)$8,000 (embedded)
OUT-OF-POCKET MAX
     Individual$6,500 (includes ded.)$13,000 (includes ded)
     Family$13,000 (embedded, includes ded.)$26,000 (embedded; includes ded.)
PHYSICIAN SERVICES
     Office Visits30% after ded.50% of Eligible Expenses after ded. + any excess charges
     Preventive Care$0 (ded. waived)Not Covered
     Diagnostic Lab/X-Ray30% after ded.50% of Eligible Expenses after ded. + any excess charges
     Imaging (CT/PET scans, MRIs)30% after ded.50% of Eligible Expenses after ded. + any excess charges
     Rehabilitation/Habilitation (PT/OT/ST)30% after ded.50% of Eligible Expenses after ded. + any excess charges
     Chiropractic Care30% after ded. (24 visits of Manipulative Treatments)50% of Eligible Expenses after ded. + any excess charges (limit combined)
PRESCRIPTION DRUGS
     Tier 1 (Generic Formulary)$15 (up to 31 day supply) (Rx Code 367)$15 + difference between Network vs. Non-Network cost (up to 31 day supply) (Rx Code 367)
     Tier 2 (Preferred Brand Formulary)$35 (up to 31 day supply) (Rx Code 367)$35 + difference between Network vs. Non-Network cost (up to 31 day supply) (Rx Code 367)
     Tier 3 (Non-Preferred Brand Formulary)$70 (up to 31 day supply) (Rx Code 367)$70 + difference between Network vs. Non-Network cost (up to 31 day supply) (Rx Code 367)
     Tier 4 (Specialty Drugs)25% (up to 31 day supply) (Rx Code 367)25% + difference between Network vs. Non-Network cost (up to 31 day supply) (Rx Code 367)
     Mail Order2.5x retail (up to 90 day supply) (Rx Code HJ)Not Covered
HOSPITAL FACILITY SERVICES
     Inpatient Hospital Services30% after ded.50% after ded. based on a percentage of the published rates allowed by Medicare for the same or similar services.
     Outpatient Surgery in a Hospital30% after ded.50% after ded. based on a percentage of the published rates allowed by Medicare for the same or similar services.
     Ambulatory Surgical Center30% after ded.50% after ded. based on a percentage of the published rates allowed by Medicare for the same or similar services.
EMERGENCY SERVICES
     Emergency Room30% after ded.Same as Network benefit
     Emergency Transport/Ambulance30% after ded.Same as Network benefit
     Urgent Care30% after ded.50% after ded. based on a percentage of the published rates allowed by Medicare for the same or similar services.
MENTAL HEALTH/SUBSTANCE USE DISORDER
     Outpatient Services30% after ded.50% after ded. based on a percentage of the published rates allowed by Medicare for the same or similar services.
     Inpatient Services30% after ded.50% after ded. based on a percentage of the published rates allowed by Medicare for the same or similar services.
MATERNITY
     Prenatal and Postnatal Care30% after ded.50% after ded. based on a percentage of the published rates allowed by Medicare for the same or similar services.
     Delivery and All Inpatient Services30% after ded.50% after ded. based on a percentage of the published rates allowed by Medicare for the same or similar services.
PEDIATRIC SERVICES (UP TO AGE 19)
     Eye Exam$0 (ded. waived, 1 exam/cal. yr.)$0 (ded. waived) based on a percentage of the published rates allowed by Medicare for the same or similar services (limit combined with In-Network).
     Glasses30% (ded. waived, 1 pair of glasses/cal. yr.)50% (ded. waived) based on a percentage of the published rates allowed by Medicare for the same or similar services (limit combined with In-Network).
     Dental Check-up$0 (ded. waived, 1 exam/6 month period)$0 (ded. waived) based on a percentage of the published rates allowed by Medicare for the same or similar services (limit combined with In-Network).