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Hospital and Surgical Charges--Charges by a hospital or physician for medical and surgical services and supplies while hospital confined are eligible expenses.  The maximum eligible expense for hospital daily room and board charges for normal care is the average semi-private room rate in that hospital.   For intensive care, the maximum eligible expense is four times the average semi-private room rate in that hospital. 

Medical Service Charges--Charges for the following medical services are eligible expenses:

• nonsurgical professional services by a physician or nurse;
• radiologist or laboratory charges for X-ray or radiation therapy, diagnosis or treatment;
• up to 30 visits per person, per calendar year of home health care by a home health care agency, but only if a hospital, skilled nursing or extended care facility confinement would otherwise be needed and the visit is prescribed by a physician;
• non-surgical treatment for tonsils, adenoids or hernia and surgical treatment for tonsils, adenoids or hernia after  coverage is in force for 6 months;
• one screening by low-dose mammography, per calendar year beginning at age 35;
• emergency air or ground transportation in an ambulance to the nearest hospital;
• if a tubal ligation is performed during a pregnancy or complication of pregnancy, then those charges will be considered as eligible expenses.  Tubal ligation and vasectomies performed as outpatient surgery are covered after the first year of coverage;
• one cytological screening per calendar year for women age 18 and older;
• coverage for one prostate cancer screening per calendar year for an insured person age 50 and over.

Medical Supply Charges--Charges for the following medical supplies are eligible expenses:

• prescription drugs;
• blood, blood plasma, oxygen and anesthesia and their administration;
• initial artificial limbs or eyes needed to replace natural limbs or eyes that are lost while an insured person's coverage is in force (however, no benefit will be paid for repair or replacement of artificial limbs or eyes, or other prosthetic devices);
• initial prosthetic devices required as a result of a mastectomy performed while an insured person's coverage is in force;
• casts, splints, surgical dressings, crutches, and the rental of wheelchairs, hospital beds, and other durable medical equipment;
• diabetic equipment and supplies prescribed by a physician. 

Dental & Cosmetic Charges--Treatment of sound, natural teeth due to bodily injury that occurs while the insured person's coverage is in force.  No benefits will be paid for the prevention or correction of teeth irregularities and malocclusion of jaws by removal, replacement, or treatment on or to teeth or any other surrounding tissue.

Cosmetic or  reconstructive surgery needed to correct a bodily injury or sickness that occurs while the insured person's coverage is in force is covered.  Cosmetic or reconstructive surgery that is not medically necessary will not be covered.

Psychiatric Care Charges--Hospital, medical service, and supply charges for psychiatric care while hospital confined are eligible expenses, up to $2,500 per insured person, per calendar year.  Outpatient psychiatric care charges including medical service and medical supply charges (including prescriptions) are paid at 50% of eligible expenses up to $40 per day up to 25 visits per calendar year.  This  benefit is limited to a maximum of $1,000 per insured person per calendar year.  $10,000 lifetime maximum benefit per insured for inpatient and outpatient combined. 

Human Organ and Transplant Charges--Hospital, medical service and medical supply charges for non-experimental human organ and/or tissue transplant charges are eligible expenses.  If the insured person uses the Transplant Network, benefits will be paid up to the amount of the charges negotiated by the Network.   In addition, there is a limited travel and lodging benefit.  If the insured person elects to have the procedure performed outside the Transplant Network, up to $100,000 will be reimbursed per procedure. 

Hospice Care--Hospice care, services and supplies, up to $5,000 per an insured person's lifetime.

Complications of Pregnancy--Complications of pregnancy covered as any other illness.  No benefits are paid for a normal pregnancy, normal childbirth, elective Cesarean Section, or elective abortion.

Emergency Room--$50 deductible per visit in addition to plan deductible, if not admitted.  If an insured person is hospital confined immediately following an emergency room visit, the emergency room deductible will not apply.

Supplemental Accident Benefit--Eligible expenses for the necessary treatment  of a bodily injury of the insured person are covered at 100% up to $500 per injury if treatment is received within 90 days after the accident causing the bodily injury.  The treatment must be ordered or given by a physician.  For treatment received after 90 days or for any amount in excess of the $500 benefit maximum per injury, the deductible and coinsurance will apply.  Drugs and medicines that are received after the first day of treatment for this bodily injury shall not be covered under this benefit. 

Celticare Plus Option Benefits--The following benefits are only available when the CeltiCare Plus Option is selected.

Preventive Care Benefit--Services for annual physical examinations and routine diagnostic or preventive testing for an asymptomatic insured person are covered at 100% up to $200 per insured person per calendar year.  The insured's deductible does not have to be met before Preventive Care Benefits are paid.

Charges for care and treatment that are eligible expenses include: low dose mammographies, routine physical examinations, routine gynecologic visits, immunizations, and laboratory testing.  Routine eye exams are covered up to $50 for per insured person per calendar year.

Healthy Lifestyle Program--25% of the charges for eligible programs that improve physical health will be covered up to $300 per calendar year, per insured person.  Eligible programs include hospital sponsored or accredited smoking cessation, weight loss or weight control programs, as well as fitness or exercise programs that are offered through hospitals, accredited or licensed health clubs, or YMCA/YWCA programs.  The deductible does not have to be met for Healthy Lifestyle Benefits to be paid.

Rx Drug  Card--

Retail purchases

• $10 copay for generic drugs
• $20 copay and a 10% coinsurance for brand-name drugs with no generic substitutes
• $20 copay and a 10% coinsurance for brand-name drugs with an available generic substitute along with 100% of the cost difference between the brand-name drug and the generic drug

Mail Order purchases

• $20 copay for generic drugs
• $40 copay and a 10% coinsurance for brand-name drugs with no generic substitutes
• $40 copay and a 10% coinsurance for brand-name drugs with an available generic substitute along with 100% of the cost difference between the brand-name drug and the generic drug

Not all prescription drugs, such as psychiatric drugs, are eligible expenses under the Rx Drug Card, but they may be eligible under the Psychiatric Care charges of the major medical plan subject to deductible and coinsurance. 

Chronic and maintenance drugs must be mail ordered.

PPO Network Charges--The following benefits are only available when a Preferred Provider Organization (PPO) is selected.

CeltiCare Select PPO Plan

Network Physician Office Visits--Services performed by a network physician for a symptomatic insured person in an office setting are covered, subject to a $10 per visit copayment amount.

Non-network Services--Each time an out-of-network provider (physician and/or hospital) is used, eligible chargers are reduced by an additional 20%, which does not apply to the out of pocket maximum.  Also, the office visit copay does not apply when non-network physicians are used.

If charges by a non-network provider  are incurred by an insured person due to a medical emergency, the deductible and coinsurance will be the same as if provided by a network provider.

CeltiCare "Any Doc" PPO Plan

Physician Office Visits--Any services performed by a physician for a symptomatic insured person in an office setting are covered, subject to a $25 per visit copayment amount.  Celtic will cover 100% of reasonable and customary charge after the per visit copayment amount up to $200.  This benefit does not apply to psychiatric office visits.

Non-network Services--Each time an out-of-network hospital is used, eligible charges are reduced by an additional 20%.  Capped at $5,000 per occurrence.

If charges by a non-network hospital are incurred by an insured person due to a medical emergency, the deductible and coinsurance will be the same as if provided by a network hospital.