Celtic Basic Health Plan

Features/Benefits	Specifics
Eligibility	Ages 6 mos. - 64 1/2 years
Plan Type	Physician and Hospital PPO
Coinsurance	80/20 Coverage after deductible of the next $10,000
Annual Deductibles	$1,500, $2,500, & $5,000 Out-of-network deductible: $1,500 + Annual Ded.
Lifetime Maximum	$5,000,000
Non-Preventive office visits to Network Provider	2 visit, $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.
Emergency Room Deductible	$250 deductible 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.
Outpatient Hospital Services (in addition to annual deductible)	$250 deductible per occurrence + Annual Deductible. Day surgery, major diagnostic procedures and medical services including charges for x-rays, lab test, EKGs and radiation therapy are eligible expenses.
Out-of-Network Services Doctors and Hospitals 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.
Home Health Care	20 visits per person, per calendar year, one visit per day.
Rehabilitation Facility	Inpatient - up to 30 days confinement per person, 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 covered per person, per calendar year for emergency air or ground ambulance service.
FREE RX Discount Card*	Use your card at more than 50,000 participating pharmacies nationwide and receive discounts on prescription drug purchases.
Optional Features/Benefits	Prescription Drug Card Option $500 Deductible Retail purchases: 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 purchases: (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
* The Rx Discount Card is a value-added feature and not part of the insurance contract. ** When the Prescription Drug Card Option is chose, it replaces the Rx Discount Card. Note: The total family deductible is the amount equal to three times the per-person deductible.