California Company
Quote Id: 1814-6241

DeltaCare 10A
Employee NameAgeTierDep CountAreaEEDepTotal
Employee 00135ES1NCAL21.0619.1640.22
Employee 002451C1NCAL21.0634.9656.02
Employee 00325EE0NCAL21.060.0021.06
Employee 00455ES1NCAL21.0619.1640.22
Employee 00565EE0NCAL21.060.0021.06
Total: 5
Rate Totals:$105.30$73.28$178.58


BenefitHMO
DEDUCTIBLE
     IndividualNone
     FamilyNone
     Waived for PreventiveNot Applicable
ELIGIBILITY
     Group Size Dental Services1-100 employees sold w/medical
     Group Size Ortho1-100 employees included as part of plan
WAITING PERIODS
     MajorNone
     Waived for major if there was prior group coverage?Not Applicable
     OrthoNone
DENTAL SERVICES
     Preventive CareNo Charge
     Basic ServicesSchedule varies based on procedure
     Major ServicesSchedule varies based on procedure
     Periodontal SurgerySchedule varies based on procedure
     Endodontic SurgerySchedule varies based on procedure
ORTHO
     Co-payChild: $1,700 Adult: $1,900
     OrthodonticsChild and Adult
     TakeoverNot Applicable
BENEFIT MAXIMUMS
     Annual Benefit MaxUnlimited
     Lifetime - Ortho1 treatment/member