California Company
Quote Id: 1814-6241

Anthem Bronze PPO 6000/35%/6600
Employee NameAgeTierDep CountAreaEEDepTotal
Employee 00135ES1CA03397.98397.98795.96
Employee 00245EC1CA03470.28206.81677.09
Employee 00325EE0CA03326.980.00326.98
Employee 00455ES1CA03726.27635.731,362.00
Employee 00565EE0CA03977.040.00977.04
Total: 5
Rate Totals:$2,898.55$1,240.52$4,139.07


BenefitPPOOut of Network
DEDUCTIBLE
     Individual$6,000$12,000
     Family$12,000 (embedded)$24,000 (embedded)
OUT-OF-POCKET MAX
     Individual$6,600 (includes ded.)$13,200 (includes ded.)
     Family$13,200 (embedded, includes ded.)$26,400 (embedded, includes ded.)
PHYSICIAN SERVICES
     Office Visits$70 copay/visit for first 3 visits and then 35% after ded.50% of allowed amount after ded.
     Preventive Care$0 (ded. waived)50% of allowed amount after ded.
     Diagnostic Lab/X-Ray35% after ded.50% of allowed amount after ded.
     Imaging (CT/PET scans, MRIs)35% after ded.50% of allowed amount after ded. ($800 max benefit/test)
     Rehabilitation/Habilitation (PT/OT/ST)$70 copay/visit for first 3 visits then 35% after ded. 50% of allowed amount after ded.
     Chiropractic Care$70 copay/visit for first 3 visits then 35% after ded. (20 visits/cal. yr.)50% of allowed amount after ded. ($25 max benefit/visit, limit combined w/PPO)
PRESCRIPTION DRUGS
     Tier 1 (Generic Formulary)$15 (30 day supply; Select Rx)50% of Drug Limited Fee Schedule. (30 day supply)
     Tier 2 (Preferred Brand Formulary)$50 (30 day supply; Select Rx)50% of Drug Limited Fee Schedule (30 day supply)
     Tier 3 (Non-Preferred Brand Formulary)$90 (30 day supply; Select Rx)50% of Drug Limited Fee Schedule (30 day supply)
     Tier 4 (Specialty Drugs)25% up to $250 max. (30 day supply; Select Rx)50% of Drug Limited Fee Schedule (30 day supply)
     Mail Order2.5x Retail [Tier 1]; 3.0x Retail [Tier 2 & 3] (90 day supply; Select Rx)Not Covered
HOSPITAL FACILITY SERVICES
     Inpatient Hospital Services35% after ded.50% of allowed amount after ded. ($650 max benefit/day)
     Outpatient Surgery in a Hospital35% after ded.50% of allowed amount after ded. ($380 max benefit/admit)
     Ambulatory Surgical Center35% after ded.50% of allowed amount after ded. ($380 max benefit/admit)
EMERGENCY SERVICES
     Emergency Room35% after ded. 35% after ded.
     Emergency Transport/Ambulance35% after ded.35% after ded.
     Urgent Care35% after ded.50% of allowed amount after ded.
MENTAL HEALTH/SUBSTANCE USE DISORDER
     Outpatient Services$70 copay/visit for first 3 visits then 35% after ded. 50% of allowed amount after ded.
     Inpatient Services35% after ded.50% of allowed amount after ded. ($650 max benefit/day)
MATERNITY
     Prenatal and Postnatal CarePrenatal: $0; Postnatal: $70 copay/visit for first 3 visits then 35% after ded. 50% of allowed amount after ded.
     Delivery and All Inpatient Services35% after ded.50% of allowed amount after ded. ($650 max benefit/day)
PEDIATRIC SERVICES (UP TO AGE 19)
     Eye Exam$0 (ded. waived, 1 exam/cal. yr.)All charges except $30 reimbursement
     Glasses$0 (ded. waived, 1 pair/cal. yr.)All charges except specified reimbursement (see EOC for details)
     Dental Check-upEmbeddedEmbedded