California Company
Quote Id: 1814-6241

Plan D PPO 1500
Employee NameAgeTierDep CountAreaEEDepTotal
Employee 00135ES1CA0B33.6935.3869.07
Employee 002451C1CA0B33.6937.0670.75
Employee 00325EE0CA0B33.690.0033.69
Employee 00455ES1CA0B33.6935.3869.07
Employee 00565EE0CA0B33.690.0033.69
Total: 5
Rate Totals:$168.45$107.82$276.27


BenefitPPOOut of Network
DEDUCTIBLE
     Individual$25$50
     Family$75$150
     Waived for PreventiveYesYes
ELIGIBILITY
     Group Size Dental Services1-100 employees sold w/medical1-100 employees sold w/medical
     Group Size OrthoNot ApplicableNot Applicable
WAITING PERIODS
     MajorNot ApplicableNot Applicable
     Waived for major if there was prior group coverage?Not ApplicableNot Applicable
     OrthoNot ApplicableNot Applicable
DENTAL SERVICES
     Preventive CareNo Charge50% of Maximum Allowable Charge
     Basic Services20%50% of Maximum Allowable Charge
     Major ServicesNot CoveredNot Covered
     Periodontal SurgeryBasicBasic
     Endodontic SurgeryBasicBasic
ORTHO
     Co-payNot CoveredNot Covered
     OrthodonticsNot ApplicableNot Applicable
     TakeoverNot ApplicableNot Applicable
BENEFIT MAXIMUMS
     Annual Benefit Max$1,500$1,500
     Lifetime - OrthoNot ApplicableNot Applicable