Celtic of Virginia CeltiCare Managed Indemnity 100/0 Plan Plan Information
Plan Type Indemnity
Office Visit for Primary Doctor Non-preventive:No Charge after Deductible
Office Visit for Specialist Non-preventive: No Charge after Deductible
Coinsurance None
Annual Deductible Individual:$5,000
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Prescription Drugs Generic: No Charge after deductible (Optional Copay Card Available) Brand: No Charge after deductible (Optional Copay Card Available) Non-Formulary: No Charge after deductible (Optional Copay Card Available)
Annual Out-of-Pocket Limit Individual:$5,000Includes deductible
Lifetime Maximum $5 Million per person
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Yes (Details in plan brochure below)
Out of Country Coverage Emergency Care Only. While traveling for up to a maximum of 90 days; Paid at out of network benefit level
Physicians
Primary Care Physician (PCP) Required No
Specialist Referrals Required No
Preventive Care Coverage
Periodic Health Exam Optional benefit
Periodic OB-GYN Exam Optional benefit
Well Baby Care Optional benefit
Prescription Drug Coverage
Generic Prescription Drugs No Charge after deductible (Optional Copay Card Available)
Brand Prescription Drugs No Charge after deductible (Optional Copay Card Available)
Non-Formulary Prescription Drugs Coverage No Charge after deductible (Optional Copay Card Available)
Mail Order for Prescription Drugs Generic: $20 Copay Brand: $40 Copay and 10% Coinsurance Non-Formulary: Not Covered Days Supply: 90
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Hospital Services Coverage
Emergency Room $50 additional deductible per visit (waived if admitted)
Outpatient Lab/X-Ray No Charge after deductible
Outpatient Surgery No Charge after deductible
Hospitalization No Charge after deductible
Maternity Coverage
Pre & Postnatal Office Visit Not Covered
Labor & Delivery Hospital Stay Not Covered
Additional Coverage
Chiropractic Coverage $500 max. per person per year
Mental Health Coverage 50% of eligible expenses up to a $40 maximum per visit, $1,000 max. per person per year
Additional Information
Application Fee No
Electronic Signature for Application Available Yes
Will insurance company obtain and pay for medical records? Yes
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