March 20, 2010

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Celtic – CeltiCare Select PPO Plan – NEVADA

A comparison of the CeltiCare Select PPO Plan offered by Celtic is detailed out below for both Network and Non-Network coverage.

  Network Non-Network
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Application CeltiCare Select PPO Plan Application CeltiCare Select PPO Plan Application
Brochure CeltiCare Select PPO Plan Brochure CeltiCare Select PPO Plan Brochure
Copay
  • Non-preventive: Six visits per person per calendar year, $15 copay for physician charges. Subesequent visits subject to deductible and coinsurance
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  • Non-preventive: Six visits per person per calendar year, $15 copay for physician charges. Subesequent visits subject to deductible and coinsurance
    		•
    Office Visit
  • Non-preventive: Six visits per person per calendar year, $15 copay for physician charges. Subesequent visits subject to deductible and coinsurance
    		•
  • Non-preventive: Six visits per person per calendar year, $15 copay for physician charges. Subesequent visits subject to deductible and coinsurance
    		•
    Deductible Individual: $1,000, Family: $3,000
  • Out of Network Deductible is $1500 + Annual Deductible
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    Coinsurance CeltiCare Select PPO Plan CeltiCare Select PPO Plan
    Coinsurance Limit CeltiCare Select PPO Plan CeltiCare Select PPO Plan
    Out-of-Pocket Maximum CeltiCare Select PPO Plan CeltiCare Select PPO Plan
    Lifetime Maximum $7 Million $7 Million
    Prescription Drugs
  • Annual Rx Deductible: $500
  • Generic Drugs: $20 copay
  • Brand Drugs with a generic substitute: $40 copay + 100% of the cost difference between the brand name drug and the generic
  • Preferred Brand Drugs: $40 copay
  • Non-preferred Brand and Specialty Drugs: $75 copay
    		•
  • Annual Rx Deductible: $500
  • Generic Drugs: $20 copay
  • Brand Drugs with a generic substitute: $40 copay + 100% of the cost difference between the brand name drug and the generic
  • Preferred Brand Drugs: $40 copay
  • Non-preferred Brand and Specialty Drugs: $75 copay
    		•
    Emergency Room
  • $250 deductible [in addition to plan deductible] waived if admitted or if charges are due to an accident
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  • $250 deductible [in addition to plan deductible] waived if admitted or if charges are due to an accident
    		•
    Adult Preventative Care Optional (Plus Option benefit) Optional (Plus Option benefit)
    Child Preventative Care Optional (Plus Option benefit) Optional (Plus Option benefit)
    Lab / X-Ray
  • Paid at 100% up to $200, then subject to deductible and coinsurance
    		•
  • Paid at 100% up to $200, then 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
  • Up to 30 visits per year
    		•
  • Up to 30 visits per year
    		•
    Skilled Nursing CeltiCare Select PPO Plan CeltiCare 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 Plus Option II includes:
    • Preventive- 100% up to $300 per person per year (after 90 day wait)
    • Supplemental Accident- Covered at 100% up to $500 per person per year
    		 Plus Option II includes:
    • Preventive- 100% up to $300 per person per year (after 90 day wait)
    • Supplemental Accident- Covered at 100% up to $500 per person per year