California Company
Quote Id: 1814-6241

Health Net Silver 70 PPO 1500/45
Employee NameAgeTierDep CountAreaEEDepTotal
Employee 00135ES1CA03435.21435.21870.42
Employee 00245EC1CA03514.27226.15740.42
Employee 00325EE0CA03357.570.00357.57
Employee 00455ES1CA03794.21695.201,489.41
Employee 00565EE0CA031,068.450.001,068.45
Total: 5
Rate Totals:$3,169.71$1,356.56$4,526.27


BenefitPPOOut of Network
DEDUCTIBLE
     Individual$1,500$3,000
     Family$3,000 (embedded-aggregate)$6,000 (embedded-aggregate)
OUT-OF-POCKET MAX
     Individual$6,500 (includes ded.)$13,000 (includes ded.)
     Family$13,000 (embedded-aggregate; includes ded.)$26,000 (embedded-aggregate; includes ded.)
PHYSICIAN SERVICES
     Office Visits$45/$70 (ded. waived)50% based on 75% of Medicare allowable after ded.
     Preventive Care$0 (ded. waived)Not Covered
     Diagnostic Lab/X-Ray$35/$65 (ded. waived)50% based on 75% of Medicare allowable after ded.
     Imaging (CT/PET scans, MRIs)20% after ded.50% based on 75% of Medicare allowable after ded.
     Rehabilitation/Habilitation (PT/OT/ST)$45 (ded. waived)Not Covered
     Chiropractic CareNot CoveredNot Covered
PRESCRIPTION DRUGS
     Tier 1 (Generic Formulary)$15 (up to a 30-day supply)Not Covered
     Tier 2 (Preferred Brand Formulary)$55 (up to a 30-day supply)Not Covered
     Tier 3 (Non-Preferred Brand Formulary)$75 (up to a 30-day supply)Not Covered
     Tier 4 (Specialty Drugs)20% up to $250/prescription (up to a 30-day supply)Not Covered
     Mail Order2x retail (up to 90 day supply)Not Covered
HOSPITAL FACILITY SERVICES
     Inpatient Hospital Services20% after ded.50% based on 190% of Medicare allowable after ded.
     Outpatient Surgery in a Hospital20% (ded. waived)50% based on 190% of Medicare allowable after ded.
     Ambulatory Surgical Center20% (ded. waived)50% based on 190% of Medicare allowable after ded.
EMERGENCY SERVICES
     Emergency Room$250 after ded. (copay waived if admitted)Paid as In-Network
     Emergency Transport/Ambulance$250 after ded.Paid as In-Network
     Urgent Care$90 (ded. waived)50% based on 75% of Medicare allowable after ded.
MENTAL HEALTH/SUBSTANCE USE DISORDER
     Outpatient Services$45 (ded. waived)50% based on 75% of Medicare allowable after ded.
     Inpatient Services20% after ded.50% based on 190% of Medicare allowable after ded.
MATERNITY
     Prenatal and Postnatal CarePrenatal: 0% (ded. waived); Postnatal: $45 (ded. waived)50% based on 75% of Medicare allowable after ded.
     Delivery and All Inpatient Services20% after ded.50% based on 190% of Medicare allowable after ded.
PEDIATRIC SERVICES (UP TO AGE 19)
     Eye Exam0% (ded. waived; 1 visit per year)Not Covered
     Glasses$0 (1 pair per year)Not Covered
     Dental Check-upPrev./Diag.: $0Prev./Diag.: $0