California Company
Quote Id: 1814-6241

Silver Access+ HMO 1700/55 OffEx
Employee NameAgeTierDep CountAreaEEDepTotal
Employee 00135ES1CA03540.30540.301,080.60
Employee 00245EC1CA03638.45280.76919.21
Employee 00325EE0CA03443.910.00443.91
Employee 00455ES1CA03985.97863.061,849.03
Employee 00565EE0CA031,326.420.001,326.42
Total: 5
Rate Totals:$3,935.05$1,684.12$5,619.17


BenefitHMO
DEDUCTIBLE
     Individual$1,700
     Family$3,400 (embedded)
OUT-OF-POCKET MAX
     Individual$6,500 (includes ded.)
     Family$13,000 (embedded; includes ded.)
PHYSICIAN SERVICES
     Office Visits$55 (ded. waived)
     Preventive Care$0 (ded. waived)
     Diagnostic Lab/X-Ray$55 (ded. waived)
     Imaging (CT/PET scans, MRIs)FreeStanding: $55 (ded. waived); OPHosp: $250 after ded.
     Rehabilitation/Habilitation (PT/OT/ST)$55 (ded. waived)
     Chiropractic Care$15/visit (up to 15 visits/year)
PRESCRIPTION DRUGS
     Tier 1 (Generic Formulary)$15 (30-day supply)
     Tier 2 (Preferred Brand Formulary)$55 (30-day supply)
     Tier 3 (Non-Preferred Brand Formulary)$75 (30-day supply)
     Tier 4 (Specialty Drugs)20% (30-day supply)
     Mail Order2x retail (90-day supply)
HOSPITAL FACILITY SERVICES
     Inpatient Hospital Services40% after ded.
     Outpatient Surgery in a Hospital40% after ded.
     Ambulatory Surgical Center40% after ded.
EMERGENCY SERVICES
     Emergency Room$275 after ded. (copay waived if directly admitted)
     Emergency Transport/Ambulance$100 (ded. waived)
     Urgent Care$55 (ded. waived)
MENTAL HEALTH/SUBSTANCE USE DISORDER
     Outpatient Services$55 (ded. waived)
     Inpatient Services40% after ded.
MATERNITY
     Prenatal and Postnatal CarePrenatal: $0 (ded. waived); Postnatal: $55 (ded. waived)
     Delivery and All Inpatient Services40% after ded.
PEDIATRIC SERVICES (UP TO AGE 19)
     Eye Exam$0 (ded. waived; 1 exam/cal. year)
     Glasses$0 (ded. waived; 1 pair of glasses/cal. yr., limitations apply)
     Dental Check-up0% (ded. waived)