March 12, 2010

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Celtic – CeltiCare Preferred "Any Doc" PPO Plan – WEST VIRGINIA

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

  Network Non-Network
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Network See Provider See Provider
Application CeltiCare Preferred "Any Doc" PPO Plan Application CeltiCare Preferred "Any Doc" PPO Plan Application
Brochure CeltiCare Preferred "Any Doc" PPO Plan Brochure CeltiCare Preferred "Any Doc" 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: $2,500, Family: $5,000 Out of Network Deductible is $1500 + Annual Deductible
    Coinsurance CeltiCare Preferred "Any Doc" PPO Plan CeltiCare Preferred "Any Doc" PPO Plan
    Coinsurance Limit CeltiCare Preferred "Any Doc" PPO Plan CeltiCare Preferred "Any Doc" PPO Plan
    Out-of-Pocket Maximum CeltiCare Preferred "Any Doc" PPO Plan CeltiCare Preferred "Any Doc" 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 "Any Doc" PPO Plan CeltiCare Preferred "Any Doc" 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 "Any Doc" PPO Plan CeltiCare Preferred "Any Doc" PPO Plan