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Arizona Health Insurance > Celtic Insurance Company > Celtic Basic Health Plan Benefits

Celtic Insurance Company

Quote & Apply - Electronic Application

Celtic Basic Health 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
Annual Plan Deductibles $1,500, $2,500, $5,000 Out-of-network deductible: $1,500 + Annual Deductible
Lifetime Maximum $5,000,000
Non-Preventive office visits to Network Provider 2 visits, $30 copay per person, per calendar year. 3rd and subsequent visits subject to annual deductible and coinsurance
Labs and X-rays Subject to annual deductible and coinsurance
Prescription Drugs $1,000 annual deductible.

Retail:

  • Generic drugs w/ no available brand: $25 copay
  • Brand drugs w/ a generic substitute: $25 copay + 100% of the cost difference between the brand name drug and the generic
  • Preferred brand drugs: 35% coinsurance
  • Non-preferred brand and specialty drugs: 50% coinsurance

Mail order : (90 day supply)

  • Generic drugs w/ no available brand: $75 copay
  • Brand drugs w/ a generic substitute: $75 copay + 100% of the cost difference between the brand name drug and the generic
  • Preferred brand drugs: 35% coinsurance
  • Non-preferred brand and specialty drugs: 50% coinsurance
Emergency Room Deductible
 $250 per visit (waived if admitted to hospital) + Annual Deductible
Hospital Confinement/Inpatient Services $500 deductible per admission + Annual Deductible. Average semi-private room rate.Intensive care at 4 times the average semi-private room rate.
Hospital Average semi-private room rate. Intensive care at 4 times the average semi-private room rate.
Outpatient Hospital Services $250 deductible per occurrence + Annual Deductible. Day surgery, major diagnostic procedures and medical services including charges for x-rays, lab tests, EKGs and radiation therapy are eligible expenses.
Out-of-Network Services Doctor and Hospital per occurrence Eligible charges reduced additional 20%, no cap
Preventive Care
(eligibility begins after 12 months of coverage)		 Eligible expenses for medical services and supplies incurred for preventive care in an asymptomatic individual are covered first dollar up to $200 per person, per calendar year.
Rehabilitation Facility Inpatient—up to 30 days confinement per person, per calendar year.
Home Health Care Up to 20 visits per calendar year.
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
Preferred Rates Preferred rates are available for qualifying applicants. Applicants and/or their spouses who have not used tobacco in the past 12 months will also receive additional premium savings.
Optional Features/Benefits Specifics
Prescription Drug Option $500 annual deductible

Retail:

  • Generic drugs w/ no available brand: $25 copay
  • Brand drugs w/ a generic substitute: $25 copay + 100% of the cost difference between the brand name drug and the generic
  • Preferred brand drugs: 35% coinsurance
  • Non-preferred brand and specialty drugs: 50% coinsurance

Mail order : (90 day supply)

  • Generic drugs w/ no available brand: $75 copay
  • Brand drugs w/ a generic substitute: $75 copay + 100% of the cost difference between the brand name drug and the generic
  • Preferred brand drugs: 35% coinsurance
  • Non-preferred brand and specialty drugs: 50% coinsurance
  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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