Celtic of Virginia CeltiCare Managed Indemnity 80/20 Plan Plan Information
Plan Type Indemnity
Office Visit for Primary Doctor Non-preventive: 20% Coinsurance after Deductible
Office Visit for Specialist Non-preventive: 20% Coinsurance after Deductible
Coinsurance 20% after deductible
Annual Deductible Individual:$5,000
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Prescription Drugs Generic: 20% Coinsurance after deductible (Optional Copay Card Available) Brand: 20% Coinsurance after deductible (Optional Copay Card Available) Non-Formulary: 20% Coinsurance after deductible (Optional Copay Card Available)
Annual Out-of-Pocket Limit Individual:$6,000Includes 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 20% Coinsurance after deductible (Optional Copay Card Available)
Brand Prescription Drugs 20% Coinsurance after deductible (Optional Copay Card Available)
Non-Formulary Prescription Drugs Coverage 20% Coinsurance 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 20% Coinsurance after deductible
Outpatient Surgery 20% Coinsurance after deductible
Hospitalization 20% Coinsurance 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
Other Celtic of Virginia health insurance plans:
