California Company
Quote Id: 1814-6241

Delta Dental Family Dental HMO
Employee NameAgeTierDep CountAreaEEDepTotal
Employee 00135ES1CA0313.9913.9927.98
Employee 002451C1CA0313.9915.4929.48
Employee 00325EE0CA0313.990.0013.99
Employee 00455ES1CA0313.9913.9927.98
Employee 00565EE0CA0313.990.0013.99
Total: 5
Rate Totals:$69.95$43.47$113.42


BenefitHMO
DEDUCTIBLE
     Individual$0
     Family$0
     Waived for PreventiveNot Applicable
ELIGIBILITY
     Group Size Dental Services1-100 Eligible
     Group Size OrthoNot Applicable
WAITING PERIODS
     MajorNone
     Waived for major if there was prior group coverage?Not Applicable
     OrthoNone
DENTAL SERVICES
     Preventive Care$0 copay
     Basic Services$25 copay (amalgam fill - one surface)
     Major Services$65-$300 copay per procedure
     Periodontal Surgery$65-$300 copay per procedure
     Endodontic Surgery$65-$300 copay per procedure
ORTHO
     Co-pay$350 (medically necessary)
     OrthodonticsChild Only (medically necessary)
     TakeoverNot Applicable
BENEFIT MAXIMUMS
     Annual Benefit MaxNone
     Lifetime - OrthoNot Applicable