California Company
Quote Id: 1814-6241

Anthem Silver PPO 2000/35%/6850
Employee NameAgeTierDep CountAreaEEDepTotal
Employee 00135ES1CA03484.35484.35968.70
Employee 00245EC1CA03572.34251.69824.03
Employee 00325EE0CA03397.950.00397.95
Employee 00455ES1CA03883.88773.691,657.57
Employee 00565EE0CA031,189.080.001,189.08
Total: 5
Rate Totals:$3,527.60$1,509.73$5,037.33


BenefitPPOOut of Network
DEDUCTIBLE
     Individual$2,000$4,000
     Family$4,000 (embedded)$8,000 (embedded)
OUT-OF-POCKET MAX
     Individual$6,850 (includes ded.)$13,700 (includes ded.)
     Family$13,700 (embedded, includes ded.)$27,400 (embedded, includes ded.)
PHYSICIAN SERVICES
     Office Visits$25/$45 copay/visit (ded. waived)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)$25 copay/visit (ded. waived)50% of allowed amount after ded.
     Chiropractic Care$25 copay/visit (ded. waived, 20 visits/cal. yr.)50% of allowed amount after ded. ($25 max benefit/visit)
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)$40 (30 day supply; Select Rx)50% of Drug Limited Fee Schedule (30 day supply)
     Tier 3 (Non-Preferred Brand Formulary)$80 (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 Room$300 copay+ 35% after ded. (copay waived if admitted)$300 copay+ 35% after ded. (copay waived if admitted)
     Emergency Transport/Ambulance35% after ded.35% after ded.
     Urgent Care$100 copay/visit (ded. waived)50% of allowed amount after ded.
MENTAL HEALTH/SUBSTANCE USE DISORDER
     Outpatient Services$25 copay/visit (ded. waived) 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: 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-upNo ChargeNo Charge