California Company
Quote Id: 1814-6241

Silver HMO B Kaiser Permanente - Full
Employee NameAgeTierDep CountAreaEEDepTotal
Employee 00135ES1CA03324.89324.89649.78
Employee 00245EC1CA03383.91184.82568.73
Employee 00325EE0CA03266.930.00266.93
Employee 00455ES1CA03592.89518.981,111.87
Employee 00565EE0CA03797.610.00797.61
Total: 5
Rate Totals:$2,366.23$1,028.69$3,394.92


BenefitHMO
DEDUCTIBLE
     Individual$1,000
     Family$2,000 (embedded)
OUT-OF-POCKET MAX
     Individual$6,500 (includes ded.)
     Family$13,000 (embedded, includes ded.)
PHYSICIAN SERVICES
     Office Visits$40 (ded. waived)
     Preventive Care$0 (ded. waived)
     Diagnostic Lab/X-RayLab: $50; X-Ray: $60 (ded. waived)
     Imaging (CT/PET scans, MRIs)$250/procedure after ded.
     Rehabilitation/Habilitation (PT/OT/ST)$40 (ded. waived)
     Chiropractic CareNot Covered
PRESCRIPTION DRUGS
     Tier 1 (Generic Formulary)$20 (30 day supply)
     Tier 2 (Preferred Brand Formulary)$50 (30 day supply)
     Tier 3 (Non-Preferred Brand Formulary)Same as preferred brand drugs when approved through exception process.
     Tier 4 (Specialty Drugs)20% up to $250 per prescription (up to 30 day supply)
     Mail Order2x retail (up to 100 day supply)
HOSPITAL FACILITY SERVICES
     Inpatient Hospital Services30% after ded.
     Outpatient Surgery in a Hospital30% after ded.
     Ambulatory Surgical Center30% after ded.
EMERGENCY SERVICES
     Emergency Room30% after ded.
     Emergency Transport/Ambulance30% after ded./trip
     Urgent Care$40 (ded. waived)
MENTAL HEALTH/SUBSTANCE USE DISORDER
     Outpatient Services$40 (ded. waived)
     Inpatient Services30% after ded.
MATERNITY
     Prenatal and Postnatal CareCovered as any illness
     Delivery and All Inpatient Services30% after ded.
PEDIATRIC SERVICES (UP TO AGE 19)
     Eye ExamKaiser Permanente: $0 (ded. waived, 1 exam/cal. yr.)
     GlassesKaiser Permanente: $0 (ded. waived, 1 pair of glasses/cal. yr., limitations apply)
     Dental Check-upDeltaCare USA, Delta Dental: Ded: None; OV: $0; OOP: $350/$700; copay based on fee schedule