California Company
Quote Id: 1814-6241

Gold Full PPO 250/20 OffEx
Employee NameAgeTierDep CountAreaEEDepTotal
Employee 00135ES1CA03521.26521.261,042.52
Employee 00245EC1CA03615.95270.87886.82
Employee 00325EE0CA03428.270.00428.27
Employee 00455ES1CA03951.23832.651,783.88
Employee 00565EE0CA031,279.680.001,279.68
Total: 5
Rate Totals:$3,796.39$1,624.78$5,421.17


BenefitPPOOut of Network
DEDUCTIBLE
     Individual$250$500
     Family$500 (embedded)$1,000 (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$20/$40 (ded. waived)40% of maximum allowable amount after ded.
     Preventive Care$0 (ded. waived)Not Covered
     Diagnostic Lab/X-Ray20% after ded.40% of maximum allowable amount after ded.
     Imaging (CT/PET scans, MRIs)FreeStanding: 20% after ded.; OPHosp: $100/visit + 20% after ded.40% of maximum allowable amount after ded.
     Rehabilitation/Habilitation (PT/OT/ST)20% after ded.40% 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)$40 (30-day supply)Not Covered
     Tier 3 (Non-Preferred Brand Formulary)$60 (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 Services20% after ded.40% of maximum allowable amount after ded.
     Outpatient Surgery in a Hospital20% after ded.40% of maximum allowable amount after ded.
     Ambulatory Surgical Center20% after ded.40% of maximum allowable amount after ded.
EMERGENCY SERVICES
     Emergency Room$100/visit + 20% after ded. (copay waived if admitted)$100/visit + 20% of maximum allowable amount after ded.
     Emergency Transport/Ambulance20% after ded.20% of maximum allowable amount after ded.
     Urgent Care$20 (ded. waived)Not Covered
MENTAL HEALTH/SUBSTANCE USE DISORDER
     Outpatient Services$20 (ded. waived)40% of maximum allowable amount after ded.
     Inpatient Services20% after ded.40% of maximum allowable amount after ded.
MATERNITY
     Prenatal and Postnatal Care$0 (ded. waived) 1st Prenatal OV, then 20% after ded. subsequent Pre and Postnatal OV40% of maximum allowable amount after ded.
     Delivery and All Inpatient Services20% after ded.40% 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)