Documentation - St. Luke's Health Plan

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Whether you're looking for plan information, forms or other legal information, you'll find it all here. Or, browse our 2025 plan info.

Expanded Bronze
SBC OOC
Expanded Bronze HDHP
SBC OOC
Individual Silver
SBC OOC
Individual Gold
SBC OOC
Individual Plans Master Policy
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Expanded Bronze
SBC OOC
Bronze HDHP
SBC OOC
Silver HDHP
SBC OOC
Silver 3500
SBC OOC
Silver 5700
SBC OOC
Silver 5500 750 Rx
SBC OOC
Gold
SBC OOC
Gold 1200 400 Rx
SBC OOC
Small Group Certificate of Coverage
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Small Group Master Policy (for Employers)
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Large Group Master Policy
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Large Group Certificate of Coverage
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Continuity of Care Form
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Grievance Form
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Higher Level of Benefits Waiver Form
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Individual Application (for enrollment outside of the Idaho Exchange)
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International Claim Form
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Medical Appeal Form
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Medical Claim Reimbursement Form
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Multiple Coverage Inquiry Form
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Qualifying Domestic Partnership Form
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Cancellation of Authorized Representative Form - Group
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Cancellation of Authorized Representative Form - Individual
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Client Portal Access Form - Small Group
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Designation of Authorized Representative Form
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Pharmacy Appeal Form
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Pharmacy Directory
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Prescription Drug Claim Form
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Provider Manual
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Multiple Coverage Inquiry Form
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Prior Authorization Form
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Provider Appeal and Claims Inquiry Form
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Release of Protected Health Information Form
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Release of Protected Health Information Form - Psychotherapy
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Plan Brochure
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Individual Booklet
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Small Group Booklet
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Silver 5600
SBC OOC
Silver 1000
SBC OOC
Silver 250
SBC OOC

Expanded Bronze Plan Limited Cost Sharing
SBC OOC
Expanded Bronze Plan Zero Cost Sharing
SBC OOC
Expanded Bronze HDHP Plan Limited Cost Sharing
SBC OOC
Expanded Bronze HDHP Plan Zero Cost Sharing
SBC OOC
Silver Plan Limited Cost Sharing
SBC OOC
Silver Plan Zero Cost Sharing
SBC OOC
Gold Plan Limited Cost Sharing
SBC OOC
Gold Plan Zero Cost Sharing
SBC OOC

Index
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Plans
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Providers
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Formulary
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Table of Contents - In Network Rates
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Allowed Amounts
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Call us at:

1-833-840-3600

Email:

[email protected]

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2026 Individual Plans

Expanded Bronze

Expanded Bronze HDHP

Individual Silver

Individual Gold

Individual Plans Master Policy

2026 Small Business Plans

Expanded Bronze

Bronze HDHP

Silver HDHP

Silver 3500

Silver 5700

Silver 5500 750 Rx

Gold

Gold 1200 400 Rx

Small Group Certificate of Coverage

Small Group Master Policy (for Employers)

2026 Large Group Documents

Large Group Master Policy

Large Group Certificate of Coverage

Individual Forms

Continuity of Care Form

Grievance Form

Higher Level of Benefits Waiver Form

Individual Application (for enrollment outside of the Idaho Exchange)

International Claim Form

Medical Appeal Form

Medical Claim Reimbursement Form

Multiple Coverage Inquiry Form

Qualifying Domestic Partnership Form

Group & Broker Forms

Cancellation of Authorized Representative Form - Group

Cancellation of Authorized Representative Form - Individual

Client Portal Access Form - Small Group

Designation of Authorized Representative Form

Pharmacy

Pharmacy Appeal Form

Pharmacy Directory

Prescription Drug Claim Form

Provider Resources & Forms

Provider Manual

Multiple Coverage Inquiry Form

Prior Authorization Form

Provider Appeal and Claims Inquiry Form

Release of Protected Health Information Form

Release of Protected Health Information Form - Psychotherapy

Marketing Materials

Plan Brochure

Individual Booklet

Small Group Booklet

2026 Individual Cost-Sharing Reduction (CSR) Plans

Silver 5600

Silver 1000

Silver 250

2026 American Indian/Alaskan Native Plans

Expanded Bronze Plan Limited Cost Sharing

Expanded Bronze Plan Zero Cost Sharing

Expanded Bronze HDHP Plan Limited Cost Sharing

Expanded Bronze HDHP Plan Zero Cost Sharing

Silver Plan Limited Cost Sharing

Silver Plan Zero Cost Sharing

Gold Plan Limited Cost Sharing

Gold Plan Zero Cost Sharing

Machine Readable Files

Index

Plans

Providers

Formulary

Table of Contents - In Network Rates

Allowed Amounts

Get in touch

A brand you can trust