California Company
Quote Id: 1814-6241

100/80/50-100/80/50 PEB 1000 U90 (Grps 2-24)
Employee NameAgeTierDep CountAreaEEDepTotal
Employee 00135ES195645.7547.5393.28
Employee 002451C195645.7552.8298.57
Employee 00325EE095645.750.0045.75
Employee 00455ES195645.7547.5393.28
Employee 00565EE095645.750.0045.75
Total: 5
Rate Totals:$228.75$147.88$376.63


BenefitPPOOut of Network
DEDUCTIBLE
     Individual$50Combined with PPO
     Family$150Combined with PPO
     Waived for PreventiveYesYes
ELIGIBILITY
     Group Size Dental Services2-24 enrolled2-24 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 Care0%0% of UCR, 90%
     Basic Services20%20% of UCR, 90th %
     Major Services50%50% of UCR, 90th %
     Periodontal SurgeryBasicBasic
     Endodontic SurgeryBasicBasic
ORTHO
     Co-payNot CoveredNot Covered
     OrthodonticsNot CoveredNot Covered
     TakeoverNot ApplicableNot Applicable
BENEFIT MAXIMUMS
     Annual Benefit Max$1,000Combined with PPO
     Lifetime - OrthoNot ApplicableNot Applicable