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Standard Gold
Health Insurance Plan Details (2024 Plan)
![Celtic Insurance Company](/assets/images/issuers/celtic-insurance-company.4f136b241a8ad9eece84.png)
by Celtic Insurance Company
Monthly Premium
EPO
$ubsidy
Gold
- Deductible
- $1,500 /yr
- Max Out-of-Pocket
- $8,700 /yr
Details
Deductible (per individual) | $1,500 /yr |
Deductible (per family) | $3,000 /yr |
Max Out-of-Pocket (per individual) | $8,700 /yr |
Max Out-of-Pocket (per family) | $17,400 /yr |
Drug Deductible (per individual) | Included in Medical |
Drug Deductible (per family) | Included in Medical |
Drug Max Out-of-Pocket (per individual) | Included in Medical |
Drug Max Out-of-Pocket (per family) | Included in Medical |
Plan Type | EPO |
Includes Child Dental? | No |
Includes Adult Dental? | No |
Out-of-Pocket Costs
Preventive Care | No Charge |
Primary Care Visit | $30 Copay |
Specialist Visit | $60 Copay |
Emergency Room | 25% Coinsurance after deductible |
Inpatient Facility | 25% Coinsurance after deductible |
Inpatient Physician | 25% Coinsurance after deductible |
Generic Drugs | $15 Copay |
Preferred Brand Drugs | $30 Copay |
Non-preferred Brand Drugs | $60 Copay |
Specialty Drugs | $250 Copay |
Plan Documents
Summary of Benefits and Coverage | SBC doc |
Provider Directory | Doctor lookup |
Drug Formulary List | drug list |
* Figures shown are only for in-network medical costs
** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible
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