CeltiCare Select PPO Plan

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What is Covered
Exclusions and Limitations
Eligibility Information

You receive high quality care for the lowest premium by accessing respected network physicians and hospitals. This doctor and hospital PPO offers savings on every visit to any network provider. In offering the CeltiCare Select PPO Plan, Celtic is in partnership with Private HealthCare Systems (PHCS), an expansive national network of doctors and hospitals.

Note: The CeltiCare "Select" PPO is available in areas in which there are preferred provider doctors and hospitals.

Features/Benefits	80/20					100%
Coinsurance	80/20 Coverage after deductible of the next $5,000					100% Coverage after deductible
Deductibles	$250	$500	$1,000	$2,500	$5,000	$1,000	$2,500	$5,000
Out-of-Pocket Maximum	$1,250	$1,500	$2,000	$3,500	$6,000	$1,000	$2,500	$5,000
Lifetime Maximum	$5,000,000					$5,000,000
Emergency Room Deductible (in addition to plan deductible)	$50 deductible per visit, if not admitted.					$50 deductible per visit, if not admitted.
Network Physician Visits	$10 copay					$10 copay
Out-of-Network Services Hospital per occurrence	Each time an out-of-network hospital is used, eligible charges are reduced by an additional 20%, which does not apply to the out-of-pocket maximum.					Each time an out-of-network hospital is used, eligible charges are reduced by an additional 20%, which does not apply to the out-of-pocket maximum.
Out-of-Network Services Doctor per occurrence	Each time an out-of-network provider is used, eligible charges are reduced by an additional 20%, which does not apply to the out-of-pocket maximum. The office visit copay does not apply when non-network physicians are used.					Each time an out-of-network provider is used, eligible charges are reduced by an additional 20%, which does not apply to the out-of-pocket maximum. The office visit copay does not apply when non-network physicians are used.
Supplemental Accident	$500 per injury					$500 per injury
FREE RX Discount Card	An average savings of 15% at over 40,000 U.S pharmacies.
Psychiatric Care*	Inpatient annual maximum of $2,500 per person, per calendar year. Outpatient annual maximum of $1,000 per person per calendar year. Lifetime maximum of $10,000 per person per inpatient and outpatient combined.
Manipulative Therapy (benefits vary by state)	$500 maximum per person, per calendar year.
Hospital	Average semi-private room rate. Intensive care at four times the average semi-private room rate.
Home Health Care	30 visits per person, per calendar year, one visit per day.
Rehabilitation Facility	Inpatient - up to 30 days confinement per person, per calendar year.
Rehabilitation Therapy	Outpatient - up to 30 visits per person, per calendar year.
Extended Care Facility	Up to 12 days of 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 and ground ambulance service.
Optional Features/Benefits	CeltiCare Plus Option					Term Life Insurance Option not available in all states