California Company
Quote Id: 1814-6241

Bronze Full PPO 4500/45 OffEx
Employee NameAgeTierDep CountAreaEEDepTotal
Employee 00135ES1CA03375.08375.08750.16
Employee 00245EC1CA03443.22194.91638.13
Employee 00325EE0CA03308.170.00308.17
Employee 00455ES1CA03684.47599.151,283.62
Employee 00565EE0CA03920.820.00920.82
Total: 5
Rate Totals:$2,731.76$1,169.14$3,900.90


BenefitPPOOut of Network
DEDUCTIBLE
     Individual$4,500$4,500
     Family$9,000 (embedded)$9,000 (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$45 after ded.50% of maximum allowable amount after ded.
     Preventive Care$0 (ded. waived)Not Covered
     Diagnostic Lab/X-Ray30% after ded.50% of maximum allowable amount after ded.
     Imaging (CT/PET scans, MRIs)FreeStanding: 30% after ded.; OPHosp: $100 + 30% after ded.50% of maximum allowable amount after ded.
     Rehabilitation/Habilitation (PT/OT/ST)30% after ded.50% 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)$50 (30-day supply)Not Covered
     Tier 3 (Non-Preferred Brand Formulary)$75 (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 Services30% after ded.50% of maximum allowable amount after ded.
     Outpatient Surgery in a Hospital30% after ded.50% of maximum allowable amount after ded.
     Ambulatory Surgical Center30% after ded.50% of maximum allowable amount after ded.
EMERGENCY SERVICES
     Emergency Room$200/visit + 30% after ded.$200/visit + 30% of maximum allowable amount after ded.
     Emergency Transport/Ambulance30% after ded.30% of maximum allowable amount after ded.
     Urgent Care$45 after ded.Not Covered
MENTAL HEALTH/SUBSTANCE USE DISORDER
     Outpatient Services$45 after ded.50% of maximum allowable amount after ded.
     Inpatient Services30% after ded.50% of maximum allowable amount after ded.
MATERNITY
     Prenatal and Postnatal Care$0 ded waived 1st Prenatal OV, then 40% after ded. subsequent Pre and Postnatal OV50% of maximum allowable amount after ded.
     Delivery and All Inpatient Services30% after ded.50% 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)