Call 800.884.2343 or
541.434.9613
FAX - 541.284.2994
General Information: Index | Exclusions & Limitations | Locate Providers | Electronic Application
Benefit Schedules: Celtic Basic | Select PPO | "Any Doc" PPO | Managed Indemnity | CelticSaver HSA
Arizona Health Insurance > Celtic Insurance Company > CeltiCare II Managed Indemnity Plan Benefits
Quote & Apply - Electronic Application
CeltiCare II Managed Indemnity Plan |
||
| Features/Benefits | Specifics | |
| Eligibility | Ages 6 months - 641⁄2 years | |
| Plan Type | No network requirements | |
| 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 | |
| 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). | |
| 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 |
|
| 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. | ||
Privacy Policy | Contact Us | ©1998-2008 CDA Insurance LLC