QUALIFIED DENTAL PLAN CONTRACT FOR 2015 betweenCovered California • March 18th, 2015
Attachment 7 Quality, Network Management and Delivery System Standards Attachment 8 Monthly Rates - Individual Exchange
QUALIFIED HEALTH PLAN CONTRACT THROUGH 2015Covered California • February 18th, 2015
Member Cost Share amounts describe the Enrollee's out of pocket costs.Actuarial Value - AV Calculator PlatinumCoinsurance Plan PlatinumCopay Plan 88.10% 88.00% Individual Overall deductible $0 $0 Other individual deductibles for specific services Medical $0 $0 Brand Drugs $0 $0 Dental $0 $0 Individual Out–of–pocket maximum $4,000 $4,000 Common Medical Event Service Type Member Cost Share Deductible Applies Member Cost Share Deductible Applies Health care provider’s office or clinic visit Primary care visit or non-specialist practitioner visit to treat an injury or illness $20 $20 Specialist visit $40 $40 Preventive care/ screening/ immunization No cost share No cost share Tests Laboratory Tests $20 $20 X-rays and Diagnostic Imaging $40 $40 Imaging (CT/PET scans, MRIs) 10% $150 Drugs to treat illness or condition Generic drugs $5 $5 Preferred brand drugs $15 $15 Non-preferred brand drugs $25 $25 Specialty drugs 10% 10% Outpatien
