| Network |
See Provider |
See Provider |
| Application |
CeltiCare Preferred Select PPO Plan Application |
CeltiCare Preferred Select PPO Plan Application |
| Brochure |
CeltiCare Preferred Select PPO Plan Brochure |
CeltiCare Preferred Select PPO Plan Brochure |
| Copay |
Select: $15 copay Any Doc: $35 copay 2 visits per person, per calendar year; 3+ visits subject to ded./coins |
Select: $15 copay Any Doc: $35 copay 2 visits per person, per calendar year; 3+ visits subject to ded./coins |
| Office Visit |
Select: $15 copay Any Doc: $35 copay 2 visits per person, per calendar year; 3+ visits subject to ded./coins |
Select: $15 copay Any Doc: $35 copay 2 visits per person, per calendar year; 3+ visits subject to ded./coins |
| Deductible |
Individual: $500, Family: $1,000 |
Out of Network Deductible is $1500 + Annual Deductible |
| Coinsurance |
CeltiCare Preferred Select PPO Plan |
CeltiCare Preferred Select PPO Plan |
| Coinsurance Limit |
CeltiCare Preferred Select PPO Plan |
CeltiCare Preferred Select PPO Plan |
| Out-of-Pocket Maximum |
CeltiCare Preferred Select PPO Plan |
CeltiCare Preferred Select PPO Plan |
| Lifetime Maximum |
$7 Million |
$7 Million |
| Prescription Drugs |
Standard Rx benefit:- Generic: $20 copay
- $500 annual deductible
- Pref. Brand: $40 copay
- Non-pref/Specialty Brand: $75 copay
- Brand w/generic alternative: specified copay + 100% cost difference btwn. Brand & Generic
Stand-alone Option:- No annual deductible for Generic
- $100 annual ded. for Brand
- Generic: $20 copay
- Pref. Brand: $40 copay
- Non-pref/Specialty Brand: $75 copay
- Brand w/generic alternative: specified copay + 100% cost difference btwn. Brand & Generic
Mail order: 90-day supply) |
Standard Rx benefit:- Generic: $20 copay
- $500 annual deductible
- Pref. Brand: $40 copay
- Non-pref/Specialty Brand: $75 copay
- Brand w/generic alternative: specified copay + 100% cost difference btwn. Brand & Generic
Stand-alone Option:- No annual deductible for Generic
- $100 annual ded. for Brand
- Generic: $20 copay
- Pref. Brand: $40 copay
- Non-pref/Specialty Brand: $75 copay
- Brand w/generic alternative: specified copay + 100% cost difference btwn. Brand & Generic
Mail order: 90-day supply) |
| Emergency Room |
$250 deductible [in addition to plan deductible] waived if admitted or if charges are due to an accident |
$250 deductible [in addition to plan deductible] waived if admitted or if charges are due to an accident |
| Adult Preventative Care |
First-dollar $300 per person, per calendar year; eligibility begins after 90 days of coverage |
First-dollar $300 per person, per calendar year; eligibility begins after 90 days of coverage |
| Child Preventative Care |
First-dollar $300 per person, per calendar year; eligibility begins after 90 days of coverage |
First-dollar $300 per person, per calendar year; eligibility begins after 90 days of coverage |
| Lab / X-Ray |
Subject to annual deductible and coinsurance |
Subject to annual deductible and coinsurance |
| Maternity |
Maternity (Prenatal/Postnatal)- Not Covered - Varies by State Maternity - Not Covered (except for complications of pregnancy) - Varies by State |
Maternity (Prenatal/Postnatal)- Not Covered - Varies by State Maternity - Not Covered (except for complications of pregnancy) - Varies by State |
| Physical Therapy |
Up to 30 visits per year |
Up to 30 visits per year |
| Skilled Nursing |
CeltiCare Preferred Select PPO Plan |
CeltiCare Preferred Select PPO Plan |
| Home Health Care |
30 visits per person, per calendar year (Varies by State) |
30 visits per person, per calendar year (Varies by State) |
| Mental Health |
Inpatient annual maximum of $2,500 per person, per calendar year. $10,000 lifetime maximum inpatient and out patient combined. Outpatient annual maximum of $1,000 per insured per calendar year. $10,000 lifetime maximum inpatient and out patient combined. |
Inpatient annual maximum of $2,500 per person, per calendar year. $10,000 lifetime maximum inpatient and out patient combined. Outpatient annual maximum of $1,000 per insured per calendar year. $10,000 lifetime maximum inpatient and out patient combined. |
| Hospital Care |
Subject to Deductible and Coinsurance |
Subject to Deductible and Coinsurance |
| Optional Benefits |
CeltiCare Preferred Select PPO Plan |
CeltiCare Preferred Select PPO Plan |