California Company
Quote Id: 1814-6241

PPO 4000
Employee NameAgeTierDep CountAreaEEDepTotal
Employee 00135ES1456.0550.45106.50
Employee 002451C1456.0550.45106.50
Employee 00325EE0456.050.0056.05
Employee 00455ES1456.0550.45106.50
Employee 00565EE0456.050.0056.05
Total: 5
Rate Totals:$280.25$151.35$431.60


BenefitPPOOut of Network
DEDUCTIBLE
     Individual$25$75
     FamilyMax 3x/FamilyMax 3x/Family
     Waived for PreventiveYesNo
ELIGIBILITY
     Group Size Dental Services1-100 Eligible1-100 Eligible
     Group Size OrthoOptional Rider (5-100 eligible)Optional Rider (5-100 eligible)
WAITING PERIODS
     Major12 months for groups with <10 eligible employees, without prior comparable group dental plan and/or newly hired employees12 months for groups with <10 eligible employees, without prior comparable group dental plan and/or newly hired employees
     Waived for major if there was prior group coverage?YesYes
     OrthoOptional Rider (24 months for groups with <10 eligible employees, without prior comparable group dental plan and/or newly hired employees)Optional Rider (24 months for groups with <10 eligible employees, without prior comparable group dental plan and/or newly hired employees)
DENTAL SERVICES
     Preventive CareNo Charge20% of UCR
     Basic Services20%/10%/0% (see carrier brochure for details)20% of UCR
     Major Services50%50% of UCR
     Periodontal SurgeryBasicMajor
     Endodontic SurgeryBasicMajor
ORTHO
     Co-payOptional Rider (50%)Optional Rider (50% of UCR)
     OrthodonticsOptional Rider (Child Only)Optional Rider (Child Only)
     TakeoverOptional Rider (Yes)Optional Rider (Yes)
BENEFIT MAXIMUMS
     Annual Benefit Max$1,200$1,000
     Lifetime - OrthoOptional Rider ($1,000/member)Optional Rider (combined with PPO)