Celtic Value One Plan Details

Company 
Plan Name  Celtic Value One
Plan Type  PPO
  Network Non-Network
Copay  N/A 
Office Visit  Services performed by a network physician for a symptomatic insured person in an office setting are covered subject to the deductible and coinsurance. 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 eligible expenses are subject to the plan deductible and coinsurance.
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  Free Rx Discount Card option or Rx Drug Card option

Free Rx Discount Card

Use this card at more than 40,000 participating pharmacies nationwide and receive discounts on prescription drug purchases and reduce your out-of-pocket prescription costs both before and after you reach your deductible.

Rx Drug Card

$500 annual deductible

Retail:
  • $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: (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.
 
Emergency Room 

in addition to annual deductible, $150 deductible per visit, (waived if admitted to hospital) 
Adult Preventive Care 

  • screening by low-dose mammography, beginning at age 35;

  • one cytological 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, or one screening per calendar year for an insured person who is at unusual risk, as determined by a physician;
  • routine physical examinations are not covered 
Child Preventive Care 

immunizations, newborn nursery charges, and routine "well baby" care of a dependent child are not covered, unless required by state law; 
Lab/X Ray  Covered: radiologist or laboratory charges for X-ray or radiation therapy, diagnosis or treatment; 
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.

If a tubal ligation is performed during a pregnancy or complication of pregnancy, then those charges will be considered as eligible expenses. Tubal ligation and vasectomies performed as outpatient surgery are covered after the first year of coverage; 
Physical Therapy 

Not covered: chronic pain disorder, acupuncture or biofeedback, or treatment including manipulation, for dislocations and subluxation of the vertebrae or spinal column; 
Skilled Nursing 

see brochure
Home Health Care 

up to 30 visits per calendar year. 
Mental Health 

Not covered: treatment of psychiatric or psychological disorders or mental nervous disorders of any kind, unless required by state law; 
Hospital Care 
  • Hospital Confinement/Inpatient Services

    in addition to annual deductible, $500 deductible per admission. Average semi-private room rate. Intensive care at 4 times the average semi-private room rate.
  • Outpatient Hospital Services

    in addition to annual deductible, $250 deductible per occurrence. Day surgery, major diagnostic procedures and medical services including charges for x-rays, lab tests, EKGs and radiation therapy are eligible expenses.
 Eligible charges reduced additional 20%, no cap
Fees 

  • no bill fee for Monthly Automatic Pay Plan. Both the monthly and quarterly billing options have an $8 per bill fee.

  • $15  One Time Application Fee 
Product Brochure

brochure  > Requires Adobe Acrobat