Celtic Care Select PPO Plan Details

CeltiCare Select PPO Plan Details

Company
Plan Name	CeltiCare Select PPO Plan
Quote or Apply	Apply
Plan Type	PPO
	Network	Non-Network
Copay	$10
Office Visit	Services performed by a network physician for a symptomatic insured person in an office setting are covered, subject to a $10 per visit copayment amount.	Each time an out-of-network provider (physician and/or hospital) is used, eligible charges are reduced by an additional 20%, which does not apply to the out-of-pocket maximum. Also, the office visit copay does not apply when non-network physicians are used. If charges by a non-network provider are incurred by an insured person due to a medical emergency, the deductible and coinsurance will be the same as if provided by a network provider.
Deductible	$10,000
Coinsurance (% Paid by Insurance Company)	70/30 Coverage after deductible of the next $10,000
Coinsurance Limit	$10,000
Annual Out-of-Pocket Limit	$13,000
Lifetime Maximum	$5,000,000
Prescription Drugs	Only available when the CeltiCare Plus Option is selected. Retail: No deductible $15 copay for generic drugs $35 copay and a 20% coinsurance for brand-name drugs with no generic substitutes $35 copay and a 20% coinsurance for brand-name drugs with an available generic substitute along with 100% of the cost difference between the brand-name drug and the generic copy. Mail order: No deductible (90 day supply) $30 copay for generic drugs $70 copay and a 20% coinsurance for brand-name drugs with no generic substitutes $70 copay and a 20% coinsurance for brand-name drugs with an available generic substitute along with 100% of the cost difference between the brand-name drug and the generic copy. Prescription drugs for psychiatric care not included
Emergency Room	(in addition to plan deductible) $50 deductible per visit, if not admitted.
Adult Preventive Care	one screening by low-dose mammography, per calendar year beginning at age 35; one cytologic screening per calendar year for women age 18 and older; coverage for one prostate cancer screening per calendar year for an insured person age 50 and over. The following are only available when the CeltiCare Plus Option is selected: Services for annual physical examinations and routine diagnostic or preventive testing for an asymptomatic insured person are covered at 100% up to $300 per insured person per calendar year. The insured's deductible does not have to be met before preventive care benefits are paid. Charges for care and treatment that are eligible expenses include: low dose mammographies, routine physical examinations, routine gynecologic visits, immunizations, and laboratory testing. Routine eye exams are covered up to $50 for per insured person per calendar year.
Child Preventive Care	routine physical examinations and "well-baby" care of a dependent child are not covered unless CeltiCare Plus option is chosen. "Well-baby" care is defined as charges not related to a sickness or bodily injury;
Lab/X Ray	radiologist or laboratory charges for X-ray or radiation therapy, diagnosis or treatment are eligible charges
Maternity	Complications of pregnancy covered as any other illness. No benefits are paid for a normal pregnancy, normal childbirth, elective Cesarean Section, or elective abortion.
Physical Therapy	see brochure
Skilled Nursing	see brochure
Home Health Care	30 visits per person, per calendar year, one visit per day.
Mental Health	Inpatient annual maximum of $2,500 per person, per calendar year. Outpatient annual maximum of $1,000 per person per calendar year. Lifetime maximum of $10,000 per person per inpatient and outpatient combined.
Hospital Care	Average semi-private room rate. Intensive care at four times the average semi-private room rate.	Eligible charges reduced additional 20%; no cap
Options	Term Life Insurance Option Ages 6 months-17 years $10,000; Ages 18-64 years $25,000; Not available in all states Celtic Plus Option including Preventive Care (see Adult Preventive Care & Child Preventive Care sections) Health Lifestyle Program (see brochure) Rx Drug Card (see Precription Drugs section)
Fees	no bill fee for Monthly Automatic Pay Plan. Both the monthly and quarterly billing options have an $8 per bill fee.
Product Brochure	brochure > Requires Adobe Acrobat Reader