California Company
Quote Id: 1814-6241

PCG 11 Classic Complete CA-2J (1R0R)
Employee NameAgeTierDep CountAreaEEDepTotal
Employee 00135ES1C59.3761.74121.11
Employee 002451C1C59.3775.25134.62
Employee 00325EE0C59.370.0059.37
Employee 00455ES1C59.3761.74121.11
Employee 00565EE0C59.370.0059.37
Total: 5
Rate Totals:$296.85$198.73$495.58


BenefitPPOOut of Network
DEDUCTIBLE
     Individual$50combined w/PPO
     Family3 members/familycombined w/PPO
     Waived for PreventiveYesYes
ELIGIBILITY
     Group Size Dental Services2-100 Enrolled2-100 Enrolled
     Group Size OrthoNot ApplicableNot Applicable
WAITING PERIODS
     MajorNoneNone
     Waived for major if there was prior group coverage?Not ApplicableNot Applicable
     OrthoNot ApplicableNot Applicable
DENTAL SERVICES
     Preventive CareNo Charge (ded. waived)No Charge (ded. waived) based on 80th percentile of claims data collected by FAIR Health. Member is responsible for costs in excess of covered expenses.
     Basic Services20% after ded. (includes oral surgery, periodontics, and endodontics)20% after ded. based on 80th percentile of claims data collected by FAIR Health. Member is responsible for costs in excess of covered expenses.
     Major Services 50% after ded.50% after ded. based on 80th percentile of claims data collected by FAIR Health. Member is responsible for costs in excess of covered expenses.
     Periodontal SurgeryBasicBasic
     Endodontic SurgeryBasicBasic
ORTHO
     Co-payNot CoveredNot Covered
     OrthodonticsNot ApplicableNot Applicable
     TakeoverNot ApplicableNot Applicable
BENEFIT MAXIMUMS
     Annual Benefit Max$2,000combined w/PPO
     Lifetime - OrthoNot ApplicableNot Applicable