Benefits Information
| Covered Benefit | Co-Payment |
|---|---|
| Outpatient Medical Care | |
| Community Health Center Visits (Primary Care and Specialist) | $0 |
| Office Visits (PCP/Specialists) | $0 |
| Outpatient Surgery (Hospital and Ambulatory Surgery Centers) | $0 |
| Abortion Services | $0 |
| X-rays/Labs | $0 |
| Inpatient Medical and Maternity Care | $0 |
| Prescription Drugs | |
| Medication via Pharmacy (1 month supply) *Generics for treatment of high blood pressure, high cholesterol, and diabetes |
Generic* $1 Generic $2 Brand $3 |
| Emergency Care | $0 |
| Inpatient Mental Health & Substance Abuse | $0 |
| Outpatient Mental Health & Substance Abuse | $0 |
| Methadone Treatment (dosing, counseling, labs) | $0 |
| Rehabilitation Services | |
| Cardiac Rehabilitation | $0 |
| Home Health Care | $0 |
| Inpatient Rehabilitation Services (combined 100 days per Contract Year) |
|
| Skilled Nursing Facility | $0 |
| Inpatient Rehabilitation or Chronic Disease Hospital | $0 |
| Short-term outpatient rehabilitation (Physical, Occupational, and Speech Therapies) |
$0 |
| Other Benefits | |
| Ambulance (emergency only) | $0 |
| Dental (restorative, preventative, radiography, diagnostic, prosthodontic, and oral surgery) |
$0 |
| Durable Medical Equipment, Supplies, Prosthetics, Oxygen & Respiratory Therapy Equipment | $0 |
| Hospice | $0 |
| Orthotics | $0 |
| Routine foot care (for diabetics) | $0 |
| Vision (exam and glasses every 24 months) | $0 |
| Wellness (Family Planning, Nutritional Counseling, Prenatal, Nurse Midwife) |
$0 |
| Annual Out-of-Pocket Expenses per benefit year | Maximum amount |
| Pharmacy | $200 |
| Covered Benefit | Co-Payment |
|---|---|
| Outpatient Medical Care | |
| Community Health Center Visits (Primary Care and Specialist) | $10/$18 |
| Office Visits (PCP/Specialists) | $10/$18 |
| Outpatient Surgery (Hospital and Ambulatory Surgery Centers) | $50 |
| Abortion Services | $50 |
| X-rays/Labs | $0 |
| Inpatient Medical and Maternity Care | $50* |
| Prescription Drugs | |
| Medication via Pharmacy (1 month supply) | Generic $10 Brand Preferred $20 Non-preferred Brand $40 |
| Maintenance Medication via CeltiCare Mail-Order Plan (3 month supply) | Generic $20 Brand Preferred $40 Non-preferred Brand $120 |
| Emergency Care | $50** |
| Inpatient Mental Health & Substance Abuse***** | $50* |
| Outpatient Mental Health & Substance Abuse***** | $10 |
| Methadone Treatment (dosing, counseling, labs) | $0 |
| Rehabilitation Services | |
| Cardiac Rehabilitation | $0 |
| Home Health Care | $0 |
| Inpatient Rehabilitation Services (combined 100 days per Contract Year) |
|
| Skilled Nursing Facility | $0 |
| Inpatient Rehabilitation or Chronic Disease Hospital | $50* |
| Short-term outpatient rehabilitation (Physical, Occupational, and Speech Therapies)*** |
$10 |
| Other Benefits**** | |
| Ambulance (emergency only) | $0 |
| Durable Medical Equipment, Supplies, Prosthetics, Oxygen & Respiratory Therapy Equipment | $0 |
| Hospice | $0 |
| Orthotics | $0 |
| Routine foot care (for diabetics) | $5 |
| Vision (exam and glasses every 24 months) | $10 |
| Wellness (Family Planning, Nutritional Counseling, Prenatal, Nurse Midwife) |
$0 |
| Annual Out-of-Pocket Expenses per benefit year | Maximum amount |
| All Services (excluding Pharmacy) | $750 |
| Pharmacy | $500 |
* Co-pay waived if transferred from another inpatient unit.
** Co-pay waived if admitted to an inpatient unit.
*** 20 combined sessions of PT/OT/ST unless waived with prior authorization.
**** Plans may offer additional benefits, but the additional costs are not part of the rate submission.
***** Inpatient and Outpatient Mental Health & Substance Abuse services are covered in accordance with medical necessity and may be subject to pre-authorization.
| Covered Benefit | Co-Payment |
|---|---|
| Outpatient Medical Care | |
| Community Health Center Visits (Primary Care and Specialist) | $15/$22 |
| Office Visits (PCP/Specialists) | $15/$22 |
| Outpatient Surgery (Hospital and Ambulatory Surgery Centers) | $125 |
| Abortion Services | $100 |
| X-rays/Labs | $0 |
| Inpatient Medical and Maternity Care | $250* |
| Prescription Drugs | |
| Medication via Pharmacy (1 month supply) | Generic $12.50 Brand Preferred $25 Non-preferred Brand $50 |
| Maintenance Medication via CeltiCare Mail-Order Plan (3 month supply) | Generic $25 Brand Preferred $50 Non-preferred Brand $150 |
| Emergency Care | $100** |
| Inpatient Mental Health & Substance Abuse | $250* |
| Outpatient Mental Health & Substance Abuse | $15 |
| Methadone Treatment (dosing, counseling, labs) | $0 |
| Rehabilitation Services | |
| Cardiac Rehabilitation | $0 |
| Home Health Care | $0 |
| Inpatient Rehabilitation Services (combined 100 days per Contract Year) |
|
| Skilled Nursing Facility | $0 |
| Inpatient Rehabilitation or Chronic Disease Hospital | $250* |
| Short-term outpatient rehabilitation (Physical, Occupational, and Speech Therapies) |
$20 |
| Other Benefits**** | |
| Ambulance (emergency only) | $0 |
| Durable Medical Equipment, Supplies, Prosthetics, Oxygen & Respiratory Therapy Equipment | 10% of cost |
| Hospice | $0 |
| Orthotics | $0 |
| Routine foot care (for diabetics) | $10 |
| Vision (exam and glasses every 24 months) | $20 |
| Wellness (Family Planning, Nutritional Counseling, Prenatal, Nurse Midwife) |
$0 |
| Annual Out-of-Pocket Expenses per benefit year | Maximum amount |
| All Services (excluding Pharmacy) | $1,500 |
| Pharmacy | $800 |
* Co-pay waived if transferred from another inpatient unit.
** Co-pay waived if admitted to an inpatient unit.
*** 20 combined sessions of PT/OT/ST unless waived with prior authorization.
**** Plans may offer additional benefits, but the additional costs are not part of the rate submission.
| Covered Benefit | Co-Payment |
|---|---|
| Outpatient Medical Care | |
| Community Health Center Visits (Primary Care and Specialist) | $0/$25 |
| Office Visits (PCP/Specialists) | $0/$25 |
| Outpatient Surgery (Hospital and Ambulatory Surgery Centers) | $50 |
| Abortion Services | $50 |
| X-rays/Labs | $0 |
| Inpatient Medical and Maternity Care | |
| Room and Board (includes deliveries/surgery/x-rays/labs) | $250* |
| Presecription Drugs | |
| Medication via Pharmacy (1 month supply) | Generic $0 Brand Preferred $50 Non-preferred Brand $50 |
| Maintenance Medication via CeltiCare Mail-Order Plan (3 month supply) | Generic $0 Brand Preferred $100 Non-preferred Brand $100 |
| Emergency Care | $100** |
| Inpatient Mental Health & Substance Abuse***** | $250* |
| Outpatient Mental Health & Substance Abuse***** | $25 |
| Methadone Treatment (dosing, counseling, labs) | $0 |
| Rehabilitation Services | |
| Cardiac Rehabilitation | $0 |
| Home Health Care | $0 |
| Inpatient Rehabilitation Services (combined 100 days per Contract Year) |
|
| Inpatient Rehabilitation or Chronic Disease Hospital | $250* |
| Short-term outpatient rehabilitation (Physical, Occupational, and Speech Therapies)*** |
$25 |
| Other Benefits**** | |
| Ambulance (emergency only) | $0 |
| Durable Medical Equipment, Supplies, Prosthetics, Oxygen & Respiratory Therapy Equipment | $50 |
| Orthotics | $0 |
| Routine foot care (for diabetics) | $10 |
| 24/7 Nurse Triage Hotline**** | $0 |
| CentAccount Healthy Rewards Program****** | $0 |
| Wellness (Family Planning, Nutritional Counseling, Prenatal, Nurse Midwife) |
$0 |
| Annual Out-of-Pocket Expenses per benefit year | Maximum amount |
| All Services (excluding Pharmacy) | $1000 |
| Pharmacy | $0 |
* Co-pay waived if transferred from another inpatient unit.
** Co-pay waived if admitted to an inpatient unit.
*** 20 combined sessions of PT/OT/ST unless waived with prior authorization.
**** Plans may offer additional benefits, but the additional costs are not part of the rate submission.
***** Inpatient and Outpatient Mental Health & Substance Abuse services are covered in accordance with medical necessity and may be subject to pre-authorization.
****** Members can earn up to $150 in the first year by completing healthy behaviors. Funds may be used towards copays or other healthcare related expenses.
