St Luke’s Health Plan Expanded Bronze – POS
Network type: POS
Coverage tier: Expanded Bronze
Primary care visit: No charge
Specialist visit: $140 copay
Urgent care visit: $140 copay
Description
Health Care Plan Details
| Network type | POS |
| Deductible | $7,750 per person $7,750 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | No charge |
| Specialist visit | $140 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $140 copay |
| Emergency room | $350 copay after deductible |
| Ambulance | 50% after deductible |
| Hospital stay (facility) | 50% after deductible |
| Hospital stay (physician) | 50% after deductible |
| Outpatient procedure (facility) | 50% after deductible |
| Outpatient procedure (physician) | 50% after deductible |
| Physical rehabilitation | $40 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 50% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $25 per script copay |
| Brand | 35% after deductible |
| Non-preferred Brand | 50% after deductible |
| Specialty | 40% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $150 per procedure copay |
| Imaging (CT/PET/MRI) | $250 per procedure after deductible copay |
| Blood work | $150 per procedure copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | No charge |
| Psychiatric hospital stay | 50% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/6NW98wBTTy9frsDAnKKj1faA.pdf |
| Drug and medication plan formulary | https://www.stlukeshealthplan.org/ |
