California Company
Quote Id: 1814-6241

Delta Dental Family Dental PPO
Employee NameAgeTierDep CountAreaEEDepTotal
Employee 00135ES1CA0349.9949.9999.98
Employee 002451C1CA0349.9932.9982.98
Employee 00325EE0CA0349.990.0049.99
Employee 00455ES1CA0349.9949.9999.98
Employee 00565EE0CA0349.990.0049.99
Total: 5
Rate Totals:$249.95$132.97$382.92


BenefitPPOOut of Network
DEDUCTIBLE
     Individual$50 per personCombined In/Out Network
     Family$50 per personCombined In/Out Network
     Waived for PreventiveYesYes
ELIGIBILITY
     Group Size Dental Services1-100 Eligible1-100 Eligible
     Group Size OrthoNot ApplicableNot Applicable
WAITING PERIODS
     Major6 months6 months
     Waived for major if there was prior group coverage?YesYes
     OrthoNot ApplicableNot Applicable
DENTAL SERVICES
     Preventive Care0% (ded. waived)20% based on MAC (ded. waived)
     Basic Services20% after ded.30% after ded. based on MAC
     Major Services50% after ded.50% after ded. based on MAC
     Periodontal Surgery50% after ded.50% after ded. based on MAC
     Endodontic Surgery50% after ded.50% after ded. based on MAC
ORTHO
     Co-pay50% after ded.50% after ded. based on MAC
     OrthodonticsNot CoveredNot Covered
     TakeoverNot ApplicableNot Applicable
BENEFIT MAXIMUMS
     Annual Benefit Max$1,500Combined In/Out Network
     Lifetime - OrthoNot ApplicableNot Applicable