| Network |
See Provider |
See Provider |
| Application |
Celtic Basic - Prescription Drug Card Option Application |
Celtic Basic - Prescription Drug Card Option Application |
| Brochure |
Celtic Basic - Prescription Drug Card Option Brochure |
Celtic Basic - Prescription Drug Card Option Brochure |
| Copay |
$30 copay for the first 2 visits per person, per year. After 2 visits, subject to annual deductible and coinsurance. |
N/A |
| Office Visit |
$30 copay for the first 2 visits per person, per year. After 2 visits, subject to annual deductible and coinsurance. |
Subject to annual deductible and coinsurance. |
| Deductible |
Individual: $5,000, Family: $10,000 |
Out of Network Deductible is $1500 + Annual Deductible |
| Coinsurance |
80/20 Coverage after deductible of the next $10,000 |
60/40 Coverage after deductible of the next $10,000 |
| Coinsurance Limit |
$10,000 |
$10,000 |
| Out-of-Pocket Maximum |
$2,000 Individual Coinsurance Maximum plus deductibles/$4,000 Family Coinsurance Maximum plus deductibles Out-of-Network charges do not apply to out-of-pocket maximum. |
$2,000 Individual Coinsurance Maximum plus deductibles/$4,000 Family Coinsurance Maximum plus deductibles Out-of-Network charges do not apply to out-of-pocket maximum. |
| Lifetime Maximum |
$5 Million |
$5 Million |
| Prescription Drugs |
$500 deductible per person per year. Generic- $25 Copay Brand- $25 Copay plus 35% coinsurance for preferred drugs or 50% coinsurance for nonpreferred/specialty drugs. (100% of cost difference if generic is available). |
$500 deductible per person per year. Generic- $25 Copay Brand- $25 Copay plus 35% coinsurance for preferred drugs or 50% coinsurance for nonpreferred/specialty drugs. (100% of cost difference if generic is available). |
| 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 |
Periodic Health Exam (Preventive Care)- Covered (no deductible) up to $200/year maximum per person. 12 Month Waiting Period for Services. Periodic OB-GYN Exam - Subject to Deductible and Coinsurance |
Well baby Care - See Periodic Health Exam: Covered in full (no deductible) up to $200/year maximum per person. 12 Month Waiting Period for Services. |
| Child Preventative Care |
Well baby Care - See Periodic Health Exam: Covered in full (no deductible) up to $200/year maximum per person. 12 Month Waiting Period for Services. |
Well baby Care - See Periodic Health Exam: Covered in full (no deductible) up to $200/year maximum per person. 12 Month Waiting Period for Services. |
| Lab / X-Ray |
Subject to Deductible and Coinsurance |
Subject to 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 |
Inpatient - up to 30 days confinement per person, per calendar year. Outpatient - not covered. |
Inpatient - up to 30 days confinement per person, per calendar year. Outpatient - not covered. |
| Skilled Nursing |
Celtic Basic - Prescription Drug Card Option |
Celtic Basic - Prescription Drug Card Option |
| Home Health Care |
20 visits per person, per calendar year, one visit per day (varies by State) |
20 visits per person, per calendar year, one visit per day (varies by State) |
| Mental Health |
Not Covered (Varies by State) |
Not Covered (Varies by State) |
| Hospital Care |
$500 deductible per admission + Annual Deductible. 80% after deductible. Outpatient surgery- $250 deductible per occurrence + Annual Deductible. Then subject to coinsurance. |
$500 deductible per admission + Annual Deductible. 60% after deductible. Outpatient surgery- $250 deductible per occurrence + Annual Deductible. Then subject to coinsurance. |
| Optional Benefits |
Celtic Basic - Prescription Drug Card Option |
Celtic Basic - Prescription Drug Card Option |
