Welcome Madiba, Inc. Employees!
Here's where you can find information about the 
health, dental & long term disability benefits available to you. 

Health

Gold PPO 500/20%/4500
​Office Visit - $30/$60 Copay (Primary Care / Specialist)
Deductible - $500 Individual / $1,500 Family
Hospital – Inpatient - 20% after ded. $200 co-pay for Emergency Room (waived if admitted) & 20% for Ambulance (after ded.)
Out-Of-Pocket Max - $4,500 Individual / $9,000 Family
RX Deductible/Copays – $250 Deductible - $15 Generic / $35 Brand Formulary / $70 Brand Non-Formulary
Bronze PPO HSA 6350/0%/6350
​Office Visit – 0% after ded. (Primary Care/Specialist)
Deductible - $6,350 Individual / $12,700 Family
0% After ded. Co-Pay Emergency Room & Ambulance
Out Of Pocket Max - $6,350 individual/ $12,700 family
RX Copays – 0% after ded. Generic / 0% after ded. Brand Formulary / 0% after ded. Brand Non-Formulary
Gold HMO 35/20%/6600
​Office Visit - $35/$60 copay (Primary Care / Specialist)
Hospital – Inpatient - $750 per day up to 3 days
$250 co-pay for Emergency Room & 20% for Ambulance
Out-Of-Pocket Max - $6,600 Individual / $13,200 Family
RX Deductible/Copays – $250 Deductible - $15 Generic after ded. / $35 after ded. Brand Formulary / $70 after ded. Brand Non-Formulary
Silver HMO 1500/30%/6550
​Office Visit – $50/$75 copay (Primary Care / Specialist)
Deductible - $1,500 Individual / $3,000 Family
Hospital – Inpatient - 30% after ded. $250 co-pay and 30% for Emergency Room (waived if admitted) & 30% for Ambulance (after ded.)
Out Of Pocket Max -  $6,550 individual/ $13,100 family
RX Copays – $500 Deductible - $15 Generic / $35 after ded. Brand Formulary / $70 after ded. Brand Non-Formulary

Medical Enrollment Form

    How do I determine my cost?
    Fill out this form and we'll get back to you with age-based rates for you and any dependents.

Find a Provider
​with Blue Cross!

Please return all completed enrollment forms to Bill Graham
Fax: (714) 979-2809
Email: billg@aclevidence.com

Once you've submitted your paperwork, 
your ID cards should arrive within 7-10 business days. 
Need to print a temporary ID card now? Click here to find out how.


Download Blue Cross' mobile app 
to access plan benefits and claims, search for a doctor, and view ID card information.

Dental
Employees have the option to enroll in this voluntary PPO dental plan.

Voluntary PPO 100/100/60 $2500 CYM

​In Network Benefits- 
      Preventative Services - 100%
        Basic Services - 100%
        Major Services - 60%
        $2500 Calendar Year Maximum

Dental Enrollment Form

Dental Plan Rates

Find a Dentist 
with Guardian!

Long Term Disability

Long Term Disability Plan

         - 60% of pre-disability earnings up to
            15,000 per month
         - 2 year Own Occupation period 
         - Maximum Benefit paid to age 65

LTD Enrollment Form

Subscribe
to our quarterly health and wellness newsletter!

Have questions about the plans available to you?

Please contact Ashbrook Clevidence with any questions regarding your current benefits and the insurance options available to you. 

Call us at (714) 755-2485!