California Company
Quote Id: 1814-6241

Silver Full PPO 1700/40 OffEx
Employee NameAgeTierDep CountAreaEEDepTotal
Employee 00135ES1CA03426.84426.84853.68
Employee 00245EC1CA03504.38221.80726.18
Employee 00325EE0CA03350.690.00350.69
Employee 00455ES1CA03778.93681.831,460.76
Employee 00565EE0CA031,047.890.001,047.89
Total: 5
Rate Totals:$3,108.73$1,330.47$4,439.20


BenefitPPOOut of Network
DEDUCTIBLE
     Individual$1,700$3,400
     Family$3,400 (embedded)$6,800 (embedded)
OUT-OF-POCKET MAX
     Individual$6,500 (includes ded.)$10,000 (includes ded.)
     Family$13,000 (embedded, includes ded.)$20,000 (embedded, includes ded.)
PHYSICIAN SERVICES
     Office Visits$40/$50 (ded. waived)50% of maximum allowable amount after ded.
     Preventive Care$0 (ded. waived)Not Covered
     Diagnostic Lab/X-Ray30% after ded.50% of maximum allowable amount after ded.
     Imaging (CT/PET scans, MRIs)FreeStanding: 30% after ded.; OPHosp: $100 +30% after ded.50% of maximum allowable amount after ded.
     Rehabilitation/Habilitation (PT/OT/ST)30% after ded.50% of maximum allowable amount after ded.
     Chiropractic Care50% (12 visits/year, ded. waived)50% of maximum allowable amount (ded. waived; 12 visits/year)
PRESCRIPTION DRUGS
     Tier 1 (Generic Formulary)$15 (30-day supply)Not Covered
     Tier 2 (Preferred Brand Formulary)$50 (30-day supply)Not Covered
     Tier 3 (Non-Preferred Brand Formulary)$75 (30-day supply)Not Covered
     Tier 4 (Specialty Drugs)30% (30-day supply)Not Covered
     Mail Order2x retail (90-day supply)Not Covered
HOSPITAL FACILITY SERVICES
     Inpatient Hospital Services30% after ded.50% of maximum allowable amount after ded.
     Outpatient Surgery in a Hospital30% after ded.50% of maximum allowable amount after ded.
     Ambulatory Surgical Center30% after ded.50% of maximum allowable amount after ded.
EMERGENCY SERVICES
     Emergency Room$200/visit + 30% after ded. (copay waived if admitted)$200/visit + 30% of maximum allowable amount after ded.
     Emergency Transport/Ambulance30% after ded.30% of maximum allowable amount after ded.
     Urgent Care$40 (ded. waived)Not Covered
MENTAL HEALTH/SUBSTANCE USE DISORDER
     Outpatient Services$40 (ded. waived)50% of maximum allowable amount after ded.
     Inpatient Services30% after ded.50% of maximum allowable amount after ded.
MATERNITY
     Prenatal and Postnatal Care$0 ded waived 1st Prenatal OV, then 30% after ded. subsequent Pre and Postnatal OV50% of maximum allowable amount after ded.
     Delivery and All Inpatient Services30% after ded.50% of maximum allowable amount after ded.
PEDIATRIC SERVICES (UP TO AGE 19)
     Eye Exam$0 (ded. waived, 1 exam/cal. year)Up to $30 maximum allowance
     Glasses$0 (ded. waived, 1 pair of glasses/cal. yr., limitations apply)SEE SCHEDULE
     Dental Check-up0% (ded. waived)20% of maximum allowable amount (ded. waived)