California Company
Quote Id: 1814-6241

Guardian Choice J1 1500 80th UCR
Employee NameAgeTierDep CountAreaEEDepTotal
Employee 00135ES1CA3564.3266.25130.57
Employee 002451C1CA3564.3292.61156.93
Employee 00325EE0CA3564.320.0064.32
Employee 00455ES1CA3564.3266.25130.57
Employee 00565EE0CA3564.320.0064.32
Total: 5
Rate Totals:$321.60$225.11$546.71


BenefitPPOOut of Network
DEDUCTIBLE
     Individual$50Combined w/PPO
     Family3 members/familyCombined w/PPO
     Waived for PreventiveYesYes
ELIGIBILITY
     Group Size Dental Services2-502-50
     Group Size OrthoNot ApplicableNot Applicable
WAITING PERIODS
     Major2-9 enrolled : 12 Months 10-50 enrolled : None2-9 enrolled : 12 Months 10-50 enrolled : None
     Waived for major if there was prior group coverage?YesYes
     OrthoNot ApplicableNot Applicable
DENTAL SERVICES
     Preventive CareNo Charge (ded. waived)Value: 0% (ded. waived) based on Fee Schedule NAP: 0% (ded. waived) based on 80th percentile of UCR
     Basic ServicesValue: 0% after ded. NAP: 20% after ded.Value: 0% after ded. based on Fee Schedule NAP: 20% of UCR, 80th % after ded.
     Major ServicesValue: 40% after ded. NAP: 50% after ded.Value: 40% after ded. based on Fee Schedule NAP: 50% after ded. based on 80th percentile of UCR
     Periodontal SurgeryBasicBasic
     Endodontic SurgeryBasicBasic
ORTHO
     Co-payNot CoveredNot Covered
     OrthodonticsNot CoveredNot Covered
     TakeoverNot ApplicableNot Applicable
BENEFIT MAXIMUMS
     Annual Benefit Max$1,500$1,500 (combined w/PPO)
     Lifetime - OrthoNot CoveredNot Covered