California Company
Quote Id: 1814-6241

Value Plan VZ 1500 Fee Schedule co
Employee NameAgeTierDep CountAreaEEDepTotal
Employee 00135ES1CA3568.7270.76139.48
Employee 002451C1CA3568.72120.83189.55
Employee 00325EE0CA3568.720.0068.72
Employee 00455ES1CA3568.7270.76139.48
Employee 00565EE0CA3568.720.0068.72
Total: 5
Rate Totals:$343.60$262.35$605.95


BenefitPPOOut of Network
DEDUCTIBLE
     Individual$50Combined w/PPO
     Family 3 members/familyCombined w/PPO
     Waived for PreventiveYesYes
ELIGIBILITY
     Group Size Dental Services5-505-50
     Group Size Ortho5-505-50
WAITING PERIODS
     Major5-9 enrolled : 12 Months 10-50 enrolled : None5-9 enrolled : 12 Months 10-50 enrolled : None
     Waived for major if there was prior group coverage?YesYes
     Ortho5-24 enrolled : 12 Months 25-50 enrolled : None5-24 enrolled : 12 Months 25-50 enrolled : None
DENTAL SERVICES
     Preventive CareNo Charge (ded. waived) 0% (ded. waived) based on Fee Schedule
     Basic Services20% after ded.20% after ded. based on Fee Schedule
     Major Services50% after ded.50% after ded. after ded. based on Fee Schedule
     Periodontal SurgeryBasicBasic
     Endodontic SurgeryBasicBasic
ORTHO
     Co-pay50% after ded.50% after ded. based on Fee Schedule
     OrthodonticsChild OnlyChild Only
     TakeoverYesYes
BENEFIT MAXIMUMS
     Annual Benefit Max$1,500$1,500 (combined w/PPO)
     Lifetime - Ortho$1,500$1,500 (combined w/PPO)