California Company
Quote Id: 1814-6241

(3-Tier) Plan 10A - Option B
Employee NameAgeTierDep CountAreaEEDepTotal
Employee 00135ES1426.3520.3646.71
Employee 002451C1426.3520.3646.71
Employee 00325EE0426.350.0026.35
Employee 00455ES1426.3520.3646.71
Employee 00565EE0426.350.0026.35
Total: 5
Rate Totals:$131.75$61.08$192.83


BenefitHMO
DEDUCTIBLE
     IndividualNone
     FamilyNone
     Waived for PreventiveNot Applicable
ELIGIBILITY
     Group Size Dental Services2-99 enrolled
     Group Size Ortho2-99 enrolled
WAITING PERIODS
     MajorNone
     Waived for major if there was prior group coverage?Not Applicable
     OrthoNone
DENTAL SERVICES
     Preventive CareNo Charge
     Basic Services$0-$175 copay/procedure
     Major Services$35-$220 copay/procedure
     Periodontal SurgerySee copay schedule
     Endodontic SurgerySee copay schedule
ORTHO
     Co-pay$25 copay (first visit), $200 start-up fee, Dependent children: $1,700 copay, Adults: $1,900 copay
     OrthodonticsChild and Adult
     TakeoverYes, amounts previously used will be applied
BENEFIT MAXIMUMS
     Annual Benefit MaxUnlimited
     Lifetime - Ortho1 treatment per member