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CELTIC

CeltiCare Preferred Select PPO 80/20 $5,000 Health Insurance Plan

A plan summary of the CELTIC California CeltiCare Preferred Select PPO 80/20 $5,000 Health Insurance Plan is detailed out below for both In Network and Out of Network coverage.

                                                In Network Out of Network

  Copay

          20%

N/A

  Office Visits

$15, first 2 visits then 20% Coinsurance after Deductible Eligible charges reduced additional 20% per occurrence.

  Annual Deductible

Individual: $5,000 Family: $15,000

Individual: $6,500 Family: $19,500

  Annual Out-Of-Pocket  Limit

Individual: $7,000 Family: $21,000

None

  Lifetime Maximum

Not Applicable Not Applicable

  Prescription Drugs

Generic: $10

Brand Formulary: $40

Brand Non-Formulary: 30%

($500 Brand Deductible)

Not Covered

  Laboratory & X-Ray

20% Coinsurance after deductible 20% Coinsurance after deductible

  Annual Physical Exam

No Charge Optional Rider Available

  Annual OB-GYN Exam

No Charge Optional Rider Available

  Well Baby Care

No Charge Optional Rider Available

  Outpatient Surgery

20% Eligible charges reduced additional 20% per occurrence.

  Emergency Room

20% plus $250

(waived if admitted)

20% plus $250 (waived if admitted)

  Inpatient Hospital

20% Eligible charges reduced additional 20% per occurrence.

  Ambulance

 20% ($5,000 maximum benefit per year)

20% ($5,000 maximum benefit per year)

  Home Health Care

20% (30 visits per year) Eligible charges reduced additional 20% per occurrence.

  Mental Health - Outpatient

 50% up to $40 per visit ($1,000 maximum benefit per year, $10,000 lifetime maximum benefit) Eligible charges reduced additional 20% per occurrence.

  Chiropractic Care

20% ($500 maximum benefit per year) Eligible charges reduced additional 20% per occurrence.

  Acupuncture

Not Covered Not Covered

  Mental Health - Inpatient

50% up to $40 per visit ($1,000 maximum benefit per year, $10,000 lifetime maximum benefit) Eligible charges reduced additional 20% per occurrence.

  Chemical Dependency

Not Covered Not Covered

  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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