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Arizona Health Insurance > Celtic Insurance Company > CeltiCare II “Any Doc” PPO Plan Benefits

Celtic Insurance Company

Quote & Apply - Electronic Application

CeltiCare II “Any Doc” PPO Plan
Features/Benefits Specifics
Eligibility Ages 6 months - 641⁄2 years
Plan Type Physician and Hospital PPO
Coinsurance 80/20 Coverage after annual plan ded. of the next $10,000 100% Coverage after annual plan ded.
Annual Plan Deductibles $500, $1,000, $1,500, $2,500, $5,000 $2,500, $5,000
Out-of-Pocket Maximum*
(includes annual plan deductible)		 $2,500, $3,000, $3,500, $4,500, $7,000 $2,500, $5,000
Lifetime Maximum $7,000,000
Non-Preventive office visits to Network Provider $35 copay/6 visits per person, per calendar year. 7th and subsequent visits subject to annual plan deductible and coinsurance.
Labs and X-rays Radiology, pathology and laboratory charges in an outpatient professional setting are paid at 100% up to $200 per person, per calendar year, then subject to annual plan deductible and coinsurance.
Prescription Drugs Prescription Drugs - $500 annual deductible. Drugs with generic alternatives require the specified copay plus 100% of the cost difference between the drug and the generic alternative. Prescriptions available by mail order with a 90 day supply.
Generic (retail)
• $20 copay		 Brand (Preferred and Nonpreferred/Specialty drugs - retail)
• $40 copay for preferred drugs
• $75 copay for nonpreferred/specialty drugs
Emergency Room Deductible
(in addition to annual plan deductible)		 $250 per visit (waived if admitted to hospital).
Out-of-Network Services
Hospital only
(in addition to annual plan deductible)		 $1,500 annual deductible. Eligible charges reduced additional 20% per occurrence.
Hospital Average semi-private room rate. Intensive care at 4 times the average semi-private room rate.
Transplants Covered up to amount negotiated by network if Transplant Network used; capped at $100,000 per procedure if insured goes out of network.
Ambulance $3,000 maximum per person, per calendar year, for emergency air or ground ambulance service.
Value-Added Benefits Specifics
Healthy Lifestyle Program Pays 25% of fees for eligible programs that improve physical health. $300 maximum per person, per calendar year.
Non-tobacco Rates and Preferred Rates Applicants and/or their spouses who have not used tobacco in the past 12 months will receive additional premium savings. Plus, Preferred Rates are available for qualifying applicants.
Optional Features/Benefits Specifics
Prescription Drug Option
(stand alone)		 Prescription Drugs - Drugs with generic alternatives require the specified copay plus 100% of the cost difference between the drug and the generic alternative. Prescriptions available by mail order with a 90 day supply.
Generic
• No deductible
• $20 copay		 Brand (Preferred and Nonpreferred/Specialty drugs)
• $100 annual deductible per person, per calendar year
• $40 copay for preferred drugs
• $75 copay for nonpreferred/specialty drugs
CeltiCare II Plus Option Preventive Care - (Eligibility begins after 90 days of coverage) Eligible expenses for medical services and supplies incurred for preventive care in an asymptomatic individual are covered at 100%, up to $300 per person, per calendar year, which includes up to $50 for routine eye exams.

Supplemental Accident - Covered at 100% up to $500 per person, per occurrence.

Prescription Drugs - Same benefit structure as stated above for the stand alone Prescription Drug Option.
Term Life Insurance Option
(not available in all states)		 Ages 6 months-17 years $10,000
Ages 18-64 years $25,000
* Based on In-Network Services Note: The total family deductible is the amount equal to three times the per-person annual deductible.  Out-of-pocket maximum is three times the per-person maximum, per calendar year, with no carry over.

 

 

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