CHRISTUS Gold – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $10 copay
Specialist visit: $35 copay
Urgent care visit: $35 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $4,200 per person $4,200 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $10 copay |
| Specialist visit | $35 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $35 copay |
| Emergency room | $950 copay after deductible |
| Ambulance | 30% coinsurance after deductible |
| Hospital stay (facility) | $950 copay per Stay after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | 30% coinsurance after deductible |
| Outpatient procedure (physician) | 30% coinsurance after deductible |
| Physical rehabilitation | $30 copay after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $950 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $4 copay |
| Brand | $35 copay |
| Non-preferred Brand | $75 copay |
| Specialty | 45% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | $20 copay |
| Imaging (CT/PET/MRI) | $200 copay after deductible |
| Blood work | 30% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $20 copay |
| Psychiatric hospital stay | $950 copay per Stay after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://chppayment.christushealth.org/documents/2024/SBC/66252_CHRISTUS_Gold.pdf |
| Drug and medication plan formulary | https://www.christushealthplan.org/member-resources/pharmacy |
| Search doctor list | https://www.christushealthplan.org/find-a-provider |
