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Home   >  Understanding Your Plan   >   Types of Plans   >   Prescriptions & Exclusions   >   Limitations & Exclusions
 
 

CELTIC

Basic 80/20 $2500 Health Insurance Plan

A plan summary of the CELTIC California Basic 80/20 $2,500 Health Insurance Plan is detailed out below for both In Network and Out of Network coverage.

                                                In Network Out of Network

  Copay

 20%

20%

  Office Visits

$30, first 2 visits then 20% Eligible charges reduced additional 20% per occurrence.

  Annual Deductible

Individual: $2,500  Family: $7,500

Individual: $4,000  Family: $12,000

  Annual Out-Of-Pocket  Limit

Individual: $4,500  Family: $13,500

None

  Lifetime Maximum

Not Applicable Not Applicable

  Prescription Drugs

Generic: $15

Preferred Brand: 35%

Non-Preferred Brand: 50%

($1,000 Brand Deductible)

Not Covered

  Laboratory & X-Ray

20% Eligible charges reduced additional 20% per occurrence.

  Annual Physical Exam

No Charge Eligible charges reduced additional 20% per occurrence.

  Annual OB-GYN Exam

No Charge Eligible charges reduced additional 20% per occurrence.

  Well Baby Care

No Charge Eligible charges reduced additional 20% per occurrence.

  Outpatient Surgery

$350 per admission plus 20% Eligible charges reduced additional 20% per occurrence.

  Emergency Room

20% plus $250

(waived if admitted)

20% plus $250

(waived if admitted)

  Inpatient Hospital

$500 per admission plus 20% Eligible charges reduced additional 20% per occurrence.

  Ambulance

20% ($3,000 maximum benefit per year)

20% ($3,000 maximum benefit per year)

  Home Health Care

20% (20 visits per year) Eligible charges reduced additional 20% per occurrence.

  Mental Health - Outpatient

  Not Covered Not Covered

  Chiropractic Care

Not Covered Not Covered

  Acupuncture

Not Covered Not Covered

  Mental Health - Inpatient

Not Covered Not Covered

  Chemical Dependency

See Benefit Contract See Benefit Contract

  Maternity Care

Not Covered Not Covered

                                                              


To learn more about your individual and family California health insurance options, the price of each plan and/or a detailed benefit summary of the plans, visit us here.

NOTICE! Final rates and benefits are based on actual plan selection (including plan riders you may request) and the assignment of any rate adjustment factors due to the health plan's underwriting guidelines.

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