California Company
Quote Id: 1814-6241

HMO 3000
Employee NameAgeTierDep CountAreaEEDepTotal
Employee 00135ES1CA11.6911.6723.36
Employee 002451C1CA11.6911.6723.36
Employee 00325EE0CA11.690.0011.69
Employee 00455ES1CA11.6911.6723.36
Employee 00565EE0CA11.690.0011.69
Total: 5
Rate Totals:$58.45$35.01$93.46


BenefitHMO
DEDUCTIBLE
     IndividualNone
     FamilyNone
     Waived for PreventiveNot Applicable
ELIGIBILITY
     Group Size Dental Services1-100 Eligible
     Group Size Ortho1-100 Eligible
WAITING PERIODS
     MajorNone
     Waived for major if there was prior group coverage?Not Applicable
     OrthoNone
DENTAL SERVICES
     Preventive CareNo Charge (1 visit/6 months)
     Basic Services$7 - $85/procedure
     Major Services$40 - $225/procedure
     Periodontal SurgerySee copay schedule
     Endodontic SurgerySee copay schedule
ORTHO
     Co-payChildren to age 18: $1,600; Adult: $1,950
     OrthodonticsAdult and Child(ren)
     TakeoverNot Applicable
BENEFIT MAXIMUMS
     Annual Benefit MaxUnlimited
     Lifetime - Ortho24 months of treatment per member