California Company
Quote Id: 1814-6241

Silver 70 PPO 1500/45 w/ Child Dental
Employee NameAgeTierDep CountAreaEEDepTotal
Employee 00135ES1CA03562.22562.221,124.44
Employee 00245EC1CA03664.35292.15956.50
Employee 00325EE0CA03461.920.00461.92
Employee 00455ES1CA031,025.98898.071,924.05
Employee 00565EE0CA031,380.240.001,380.24
Total: 5
Rate Totals:$4,094.71$1,752.44$5,847.15


BenefitPPOOut of Network
DEDUCTIBLE
     Individual$1,500$3,000
     Family$3,000 (embedded)$6,000 (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 Visits$45/$70 (ded. waived)40% after ded. (based on MAC)
     Preventive Care$0 (ded. waived)40% (ded. waived; based on MAC)
     Diagnostic Lab/X-Ray$35/$65 (ded. waived)40% after ded. (based on MAC)
     Imaging (CT/PET scans, MRIs)$250 (ded. waived)40% after ded. (based on MAC)
     Rehabilitation/Habilitation (PT/OT/ST)$45 (ded. waived, 60 visits/cal. yr.)40% after ded. (based on MAC)
     Chiropractic CareNot CoveredNot Covered
PRESCRIPTION DRUGS
     Tier 1 (Generic Formulary)$15 (30 day supply)Not Covered
     Tier 2 (Preferred Brand Formulary)$55 (30 day supply)Not Covered
     Tier 3 (Non-Preferred Brand Formulary)Same as preferred brand drugsNot Covered
     Tier 4 (Specialty Drugs)20% up to $250 max (up to 30 day supply)Not Covered
     Mail Order2x retail (up to 100 day supply, excludes self-injectable drugs)Not Covered
HOSPITAL FACILITY SERVICES
     Inpatient Hospital Services20% after ded.40% after ded. (based on MAC)
     Outpatient Surgery in a Hospital20% after ded.40% after ded. (based on MAC)
     Ambulatory Surgical Center20% after ded.40% after ded. (based on MAC)
EMERGENCY SERVICES
     Emergency Room$300 after ded. (waived if admitted directly to hospital)Paid as In-Network
     Emergency Transport/Ambulance$250 after ded.Paid as In-Network
     Urgent Care$90 (ded. waived)40% after ded. (based on MAC)
MENTAL HEALTH/SUBSTANCE USE DISORDER
     Outpatient Services$45 (ded. waived)40% after ded. (based on MAC)
     Inpatient Services20% after ded.40% after ded. (based on MAC)
MATERNITY
     Prenatal and Postnatal Care$0 (ded. waived, scheduled prenatal and first postnatal)40% after ded. (based on MAC)
     Delivery and All Inpatient Services20% after ded.40% after ded. (based on MAC)
PEDIATRIC SERVICES (UP TO AGE 19)
     Eye ExamKaiser Permanente: $0 (ded. waived, 1 exam/cal. yr.)$0 after ded.
     GlassesKaiser Permanente: $0 (ded. waived; 1 pair of glasses/cal. yr, limitations apply)20% after ded. (based on MAC)
     Dental Check-upDelta Dental PPO: $0 (ded. waived)$0 (ded. waived)