California Company
Quote Id: 1814-6241

Smile (SM) 50/1500/No Ortho/MAC
Employee NameAgeTierDep CountAreaEEDepTotal
Employee 00135ES1CA0343.4042.4085.80
Employee 002451C1CA0343.4054.6098.00
Employee 00325EE0CA0343.400.0043.40
Employee 00455ES1CA0343.4042.4085.80
Employee 00565EE0CA0343.400.0043.40
Total: 5
Rate Totals:$217.00$139.40$356.40


BenefitPPOOut of Network
DEDUCTIBLE
     Individual$50combined w/PPO
     Family3 members/familycombined w/PPO
     Waived for PreventiveYesYes
ELIGIBILITY
     Group Size Dental Services1-100 enrolled1-100 enrolled
     Group Size OrthoNot ApplicableNot Applicable
WAITING PERIODS
     MajorNoneNone
     Waived for major if there was prior group coverage?Not ApplicableNot Applicable
     OrthoNot ApplicableNot Applicable
DENTAL SERVICES
     Preventive CareNo Charge (ded. waived)20% (ded. waived) based on MAC.
     Basic Services20% after ded.30% after ded. based on MAC.
     Major Services50% after ded.50% after ded. based on MAC.
     Periodontal SurgeryBasicBasic
     Endodontic SurgeryBasicBasic
ORTHO
     Co-payNot CoveredNot Covered
     OrthodonticsNot CoveredNot Covered
     TakeoverNot ApplicableNot Applicable
BENEFIT MAXIMUMS
     Annual Benefit Max$1,500$750 (combined w/PPO)
     Lifetime - OrthoNot CoveredNot Covered