St Luke’s Health Plan Gold – POS
Network type: POS
Coverage tier: Gold
Primary care visit: No charge
Specialist visit: $30 copay
Urgent care visit: $30 copay
Description
Health Care Plan Details
| Network type | POS |
| Deductible | $1,800 per person $1,800 per person |
| Out-of-pocket max | $7,750 per person $15,500 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | No charge |
| Specialist visit | $30 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $30 copay |
| Emergency room | $100 copay after deductible |
| Ambulance | 10% after deductible |
| Hospital stay (facility) | 10% after deductible |
| Hospital stay (physician) | 10% after deductible |
| Outpatient procedure (facility) | 10% after deductible |
| Outpatient procedure (physician) | 10% after deductible |
| Physical rehabilitation | $25 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 10% after deductible |
Pharmacy, Drugs, and Medication
| Generic | No charge |
| Brand | 35% after deductible |
| Non-preferred Brand | 50% after deductible |
| Specialty | 40% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $40 per procedure copay |
| Imaging (CT/PET/MRI) | $150 per procedure after deductible copay |
| Blood work | $40 per procedure copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | No charge |
| Psychiatric hospital stay | 10% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/rxytH5kGh8zR62XyEZk3ARY8.pdf |
| Drug and medication plan formulary | https://www.stlukeshealthplan.org/ |
