Individual and Family Plans

English

• 2024 Louisiana Health Insurance Exchange - Off Exchange Evidence of Coverage (PDF)
• 2024 Louisiana Health Insurance Exchange - On Exchange Evidence of Coverage (PDF)

Spanish

• 2024 Louisiana Health Insurance Exchange - Off Exchange Evidence of Coverage (PDF)
• 2024 Louisiana Health Insurance Exchange - On Exchange Evidence of Coverage (PDF)

English

• Louisiana Silver HD Summary of Benefits (PDF)
• Louisiana American Indian Zero Cost Sharing Summary of Benefits (PDF)
• Louisiana Silver HD Limited Summary of Benefits (PDF)
• Louisiana Silver HD 73% Summary of Benefits (PDF)
• Louisiana Silver HD 87% Summary of Benefits (PDF)
• Louisiana Silver HD 94% Summary of Benefits (PDF)
• Louisiana Gold Summary of Benefits (PDF)
• Louisiana Gold Limited Summary of Benefits (PDF)
• Louisiana Bronze Summary of Benefits (PDF)
• Louisiana Bronze Limited Summary of Benefits (PDF)
• Louisiana Silver Summary of Benefits (PDF)
• Louisiana Silver Limited Summary of Benefits (PDF)
• Louisiana Silver 73% Summary of Benefits (PDF)
• Louisiana Silver 87% Summary of Benefits (PDF)
• Louisiana Silver 94% Summary of Benefits (PDF)
• Louisiana Gold Plus Summary of Benefits (PDF)
• Louisiana American Indian Zero Cost Sharing Plus Summary of Benefits (PDF)
• Louisiana Gold Plus Limited Summary of Benefits (PDF)
• Louisiana Bronze Basic Summary of Benefits (PDF)
• Louisiana Bronze Basic Limited Summary of Benefits (PDF)
• Louisiana Standard Silver Summary of Benefits (PDF)
• Louisiana Standard Silver Limited Summary of Benefits (PDF)
• Louisiana Standard Silver 73% Summary of Benefits (PDF)
• Louisiana Standard Silver 87% Summary of Benefits (PDF)
• Louisiana Standard Silver 94% Summary of Benefits (PDF)
• Louisiana Standard Gold Summary of Benefits (PDF)
• Louisiana Standard Gold Limited Summary of Benefits (PDF)
• Louisiana Standard Expanded Bronze Summary of Benefits (PDF)
• Louisiana Standard Expanded Bronze Limited Summary of Benefits (PDF)

Spanish

• Louisiana Silver HD Summary of Benefits (PDF)
• Louisiana American Indian Zero Cost Sharing Summary of Benefits (PDF)
• Louisiana Silver HD Limited Summary of Benefits (PDF)
• Louisiana Silver HD 73% Summary of Benefits (PDF)
• Louisiana Silver HD 87% Summary of Benefits (PDF)
• Louisiana Silver HD 94% Summary of Benefits (PDF)
• Louisiana Gold Summary of Benefits (PDF)
• Louisiana Gold Limited Summary of Benefits (PDF)
• Louisiana Bronze Summary of Benefits (PDF)
• Louisiana Bronze Limited Summary of Benefits (PDF)
• Louisiana Silver Summary of Benefits (PDF)
• Louisiana Silver Limited Summary of Benefits (PDF)
• Louisiana Silver 73% Summary of Benefits (PDF)
• Louisiana Silver 87% Summary of Benefits (PDF)
• Louisiana Silver 94% Summary of Benefits (PDF)
• Louisiana Gold Plus Summary of Benefits (PDF)
• Louisiana American Indian Zero Cost Sharing Plus Summary of Benefits (PDF)
• Louisiana Gold Plus Limited Summary of Benefits (PDF)
• Louisiana Bronze Basic Summary of Benefits (PDF)
• Louisiana Bronze Basic Limited Summary of Benefits (PDF)
• Louisiana Standard Silver Summary of Benefits (PDF)
• Louisiana Standard Silver Limited Summary of Benefits (PDF)
• Louisiana Standard Silver 73% Summary of Benefits (PDF)
• Louisiana Standard Silver 87% Summary of Benefits (PDF)
• Louisiana Standard Silver 94% Summary of Benefits (PDF)
• Louisiana Standard Gold Summary of Benefits (PDF)
• Louisiana Standard Gold Limited Summary of Benefits (PDF)
• Louisiana Standard Expanded Bronze Summary of Benefits (PDF)
• Louisiana Standard Expanded Bronze Limited Summary of Benefits (PDF)

English

• Louisiana American Indian Zero Cost Sharing Schedule of Benefits (PDF)
• Louisiana American Indian Zero Cost Sharing Plus Schedule of Benefits (PDF)
• Louisiana Bronze Schedule of Benefits (PDF)
• Louisiana Bronze Basic Schedule of Benefits (PDF)
• Louisiana Bronze Basic Limited Schedule of Benefits (PDF)
• Louisiana Bronze Limited Schedule of Benefits (PDF)
• Louisiana Gold Schedule of Benefits (PDF)
• Louisiana Gold Limited Schedule of Benefits (PDF)
• Louisiana Gold Plus Schedule of Benefits (PDF)
• Louisiana Gold Plus Limited Schedule of Benefits (PDF)
• Louisiana Silver Schedule of Benefits (PDF)
• Louisiana Silver 73% Schedule of Benefits (PDF)
• Louisiana Silver 87% Schedule of Benefits (PDF)
• Louisiana Silver 94% Schedule of Benefits (PDF)
• Louisiana Silver HD Limited Schedule of Benefits (PDF)
• Louisiana Silver Limited Schedule of Benefits (PDF)
• Louisiana Silver HD Schedule of Benefits (PDF)
• Louisiana Silver HD 73% Schedule of Benefits (PDF)
• Louisiana Silver HD 87% Schedule of Benefits (PDF)
• Louisiana Silver HD 94% Schedule of Benefits (PDF)
• Louisiana Standard Expanded Bronze Schedule of Benefits (PDF)
• Louisiana Standard Expanded Bronze Limited Schedule of Benefits (PDF)
• Louisiana Standard Gold Schedule of Benefits (PDF)
• Louisiana Standard Gold Limited Schedule of Benefits (PDF)
• Louisiana Standard Silver Schedule of Benefits (PDF)
• Louisiana Standard Silver 73% Schedule of Benefits (PDF)
• Louisiana Standard Silver 87% Schedule of Benefits (PDF)
• Louisiana Standard Silver 94% Schedule of Benefits (PDF)
• Louisiana Standard Silver Limited Schedule of Benefits (PDF)

Spanish

• Louisiana American Indian Zero Cost Sharing Plus Schedule of Benefits (PDF)
• Louisiana American Indian Zero Cost Sharing Schedule of Benefits (PDF)
• Louisiana Bronze Basic Limited Schedule of Benefits (PDF)
• Louisiana Bronze Basic Schedule of Benefits (PDF)
• Louisiana Bronze Limited Schedule of Benefits (PDF)
• Louisiana Bronze Schedule of Benefits (PDF)
• Louisiana Gold Limited Schedule of Benefits (PDF)
• Louisiana Gold Plus Limited Schedule of Benefits (PDF)
• Louisiana Gold Plus Schedule of Benefits (PDF)
• Louisiana Gold Schedule of Benefits (PDF)
• Louisiana Silver 73% Schedule of Benefits (PDF)
• Louisiana Silver 87% Schedule of Benefits (PDF)
• Louisiana Silver 94% Schedule of Benefits (PDF)
• Louisiana Silver Limited Schedule of Benefits (PDF)
• Louisiana Silver Schedule of Benefits (PDF)
• Louisiana Silver HD 73% Schedule of Benefits (PDF)
• Louisiana Silver HD 87% Schedule of Benefits (PDF)
• Louisiana Silver HD 94% Schedule of Benefits (PDF)
• Louisiana Silver HD Limited Schedule of Benefits (PDF)
• Louisiana Silver HD Schedule of Benefits (PDF)
• Louisiana Standard Expanded Bronze Limited Schedule of Benefits (PDF)
• Louisiana Standard Expanded Bronze Schedule of Benefits (PDF)
• Louisiana Standard Gold Limited Schedule of Benefits (PDF)
• Louisiana Standard Gold Schedule of Benefits (PDF)
• Louisiana Standard Silver 73% Schedule of Benefits (PDF)
• Louisiana Standard Silver 87% Schedule of Benefits (PDF)
• Louisiana Standard Silver 94% Schedule of Benefits (PDF)
• Louisiana Standard Silver Limited Schedule of Benefits (PDF)
• Louisiana Standard Silver Schedule of Benefits (PDF)

English

• 2024 Texas Health Insurance Exchange - Platinum Evidence of Coverage (PDF)
• 2024 Texas Health Insurance Exchange - Off Exchange Evidence of Coverage (PDF)
• 2024 Texas Health Insurance Exchange - On Exchange Evidence of Coverage (PDF)

Spanish

• 2024 Texas Health Insurance Exchange - Platinum Evidence of Coverage (PDF)
• 2024 Texas Health Insurance Exchange - Off Exchange Evidence of Coverage (PDF)
• 2024 Texas Health Insurance Exchange - On Exchange Evidence of Coverage (PDF)

English

• Texas American Indian Zero Cost Sharing Summary of Benefits (PDF)
• Texas American Indian Zero Cost Sharing Plus Summary of Benefits (PDF)
• Texas Bronze Summary of Benefits (PDF)
• Texas Bronze Limited Summary of Benefits (PDF)
• Texas Bronze Plus Summary of Benefits (PDF)
• Texas Bronze Plus Limited Summary of Benefits (PDF)
• Texas Catastrophic Summary of Benefits (PDF)
• Texas Gold Summary of Benefits (PDF)
• Texas Gold Limited Summary of Benefits (PDF)
• Texas Gold Plus Summary of Benefits (PDF)
• Texas Gold Plus Limited Summary of Benefits (PDF)
• Texas Platinum Summary of Benefits (PDF)
• Texas Silver Summary of Benefits (PDF)
• Texas Silver 73% Summary of Benefits (PDF)
• Texas Silver 87% Summary of Benefits (PDF)
• Texas Silver 94% Summary of Benefits (PDF)
• Texas Silver HD Summary of Benefits (PDF)
• Texas Silver HD 73% Summary of Benefits (PDF)
• Texas Silver HD 87% Summary of Benefits (PDF)
• Texas Silver HD 94% Summary of Benefits (PDF)
• Texas Silver HD Limited Summary of Benefits (PDF)
• Texas Silver Limited Summary of Benefits (PDF)
• Texas Standard Expanded Bronze Summary of Benefits (PDF)
• Texas Standard Expanded Bronze Limited Summary of Benefits (PDF)
• Texas Standard Gold Summary of Benefits (PDF)
• Texas Standard Gold Limited Summary of Benefits (PDF)
• Texas Standard Silver Summary of Benefits (PDF)
• Texas Standard Silver 73% Summary of Benefits (PDF)
• Texas Standard Silver 87% Summary of Benefits (PDF)
• Texas Standard Silver 94% Summary of Benefits (PDF)
• Texas Standard Silver Limited Summary of Benefits (PDF)

Spanish

• Texas American Indian Zero Cost Sharing Summary of Benefits - Spanish (PDF)
• Texas American Indian Zero Cost Sharing Plus Summary of Benefits - Spanish (PDF)
• Texas Bronze Summary of Benefits - Spanish (PDF)
• Texas Bronze Limited Summary of Benefits - Spanish (PDF)
• Texas Bronze Plus Summary of Benefits - Spanish (PDF)
• Texas Bronze Plus Limited Summary of Benefits - Spanish (PDF)
• Texas Catastrophic Summary of Benefits - Spanish (PDF)
• Texas Gold Summary of Benefits - Spanish (PDF)
• Texas Gold Limited Summary of Benefits - Spanish (PDF)
• Texas Gold Plus Summary of Benefits - Spanish (PDF)
• Texas Gold Plus Limited Summary of Benefits - Spanish (PDF)
• Texas Platinum Summary of Benefits - Spanish (PDF)
• Texas Silver Summary of Benefits - Spanish (PDF)
• Texas Silver 73% Summary of Benefits - Spanish (PDF)
• Texas Silver 87% Summary of Benefits - Spanish (PDF)
• Texas Silver 94% Summary of Benefits - Spanish (PDF)
• Texas Silver HD Summary of Benefits - Spanish (PDF)
• Texas Silver HD 73% Summary of Benefits - Spanish (PDF)
• Texas Silver HD 87% Summary of Benefits - Spanish (PDF)
• Texas Silver HD 94% Summary of Benefits - Spanish (PDF)
• Texas Silver HD Limited Summary of Benefits - Spanish (PDF)
• Texas Silver Limited Summary of Benefits - Spanish (PDF)
• Texas Standard Expanded Bronze Summary of Benefits - Spanish (PDF)
• Texas Standard Expanded Bronze Limited Summary of Benefits - Spanish (PDF)
• Texas Standard Gold Summary of Benefits - Spanish (PDF)
• Texas Standard Gold Limited Summary of Benefits - Spanish (PDF)
• Texas Standard Silver Summary of Benefits - Spanish (PDF)
• Texas Standard Silver 73% Summary of Benefits - Spanish (PDF)
• Texas Standard Silver 87% Summary of Benefits - Spanish (PDF)
• Texas Standard Silver 94% Summary of Benefits - Spanish (PDF)
• Texas Standard Silver Limited Summary of Benefits - Spanish (PDF)

English

• Texas American Indian Zero Cost Sharing Schedule of Benefits (PDF)
• Texas American Indian Zero Cost Sharing Plus Schedule of Benefits (PDF)
• Texas Bronze Schedule of Benefits (PDF)
• Texas Bronze Limited Schedule of Benefits (PDF)
• Texas Bronze Plus Schedule of Benefits (PDF)
• Texas Bronze Plus Limited Schedule of Benefits (PDF)
• Texas Catastrophic Schedule of Benefits (PDF)
• Texas Gold Schedule of Benefits (PDF)
• Texas Gold Limited Schedule of Benefits (PDF)
• Texas Gold Plus Schedule of Benefits (PDF)
• Texas Gold Plus Limited Schedule of Benefits (PDF)
• Texas Platinum Schedule of Benefits (PDF)
• Texas Silver Schedule of Benefits (PDF)
• Texas Silver 73% Schedule of Benefits (PDF)
• Texas Silver 87% Schedule of Benefits (PDF)
• Texas Silver 94% Schedule of Benefits (PDF)
• Texas Silver HD Limited Schedule of Benefits (PDF)
• Texas Silver Limited Schedule of Benefits (PDF)
• Texas Silver HD Schedule of Benefits (PDF)
• Texas Silver HD 73% Schedule of Benefits (PDF)
• Texas Silver HD 87% Schedule of Benefits (PDF)
• Texas Silver HD 94% Schedule of Benefits (PDF)
• Texas Standard Expanded Bronze Schedule of Benefits (PDF)
• Texas Standard Expanded Bronze Limited Schedule of Benefits (PDF)
• Texas Standard Gold Schedule of Benefits (PDF)
• Texas Standard Gold Limited Schedule of Benefits (PDF)
• Texas Standard Silver Schedule of Benefits (PDF)
• Texas Standard Silver 73% Schedule of Benefits (PDF)
• Texas Standard Silver 87% Schedule of Benefits (PDF)
• Texas Standard Silver 94% Schedule of Benefits (PDF)
• Texas Standard Silver Limited Schedule of Benefits (PDF)

Spanish

• Texas American Indian Zero Cost Sharing Plus Schedule of Benefits (PDF)
• Texas American Indian Zero Cost Sharing Schedule of Benefits (PDF)
  
• Texas Bronze Limited Schedule of Benefits (PDF)
  
• Texas Bronze Plus Limited Schedule of Benefits (PDF)
  
• Texas Bronze Plus Schedule of Benefits (PDF)
  
• Texas Bronze Schedule of Benefits (PDF)
  
• Texas Catastrophic Schedule of Benefits (PDF)
  
• Texas Gold Plus Schedule of Benefits (PDF)
  
• Texas Gold Limited Schedule of Benefits (PDF)
  
• Texas Gold Plus Limited Schedule of Benefits (PDF)
  
• Texas Gold Schedule of Benefits (PDF)
• Texas Platinum Schedule of Benefits (PDF)
• Texas Silver 73% Schedule of Benefits (PDF)
• Texas Silver 87% Schedule of Benefits (PDF)
• Texas Silver 94% Schedule of Benefits (PDF)
• Texas Silver Limited Schedule of Benefits (PDF)
• Texas Silver Schedule of Benefits (PDF)
• Texas Silver HD 73% Schedule of Benefits (PDF)
• Texas Silver HD 87% Schedule of Benefits (PDF)
• Texas Silver HD 94% Schedule of Benefits (PDF)
• Texas Silver HD Limited Schedule of Benefits (PDF)
• Texas Silver HD Schedule of Benefits (PDF)
• Texas Standard Expanded Bronze Limited Schedule of Benefits (PDF)
• Texas Standard Expanded Bronze Schedule of Benefits (PDF)
• Texas Standard Gold Limited Schedule of Benefits (PDF)
• Texas Standard Gold Schedule of Benefits (PDF)
• Texas Standard Silver 73% Schedule of Benefits (PDF)
• Texas Standard Silver 87% Schedule of Benefits (PDF)
• Texas Standard Silver 94% Schedule of Benefits (PDF)
• Texas Standard Silver Limited Schedule of Benefits (PDF)
• Texas Standard Silver Schedule of Benefits (PDF)

If you choose to go out-of-network for your dental care, you may be reimbursed for your treatment. Complete the patient and subscriber information on the Delta Dental Claims Form.

Mail the completed form and a copy of the dentist’s Statement of Treatment (or detailed receipt) to:
Delta Dental Insurance Company
PO Box 1809
Alpharetta, GA 30023

The Statement of Treatment or detailed receipt must include:

• Name, address, and complete phone number of dentist
• Date each service was performed
• Description, procedure code, and fee of each service performed
• List of affected teeth
• Total cost of services performed
• Dentist’s National Provider Identifier (NPI)
• Dentist’s Tax Identification Number (TIN)
• State license number
• Specialty code

Important note: If the Statement of Treatment or similar document you receive from your dentist is missing any of the information listed above, please enter it on the claim form. A dental office staff member can provide you with the dentist and treatment information.

Be sure to make a copy of the completed claim form and the dentist’s Statement of Treatment or detailed receipt for your records.

2024 - Plus Members

Your fitness benefit for 2024 is offered through the Active&Fit Enterprise™ program and does not require reimbursement. Please visit ActiveandFit.com to register for your account and to find one of the thousands of fitness centers near you. Bronze Plus, Silver Plus, and Gold Plus Members only.

If you are a 2023 member in a CHRISTUS Health Plan Bronze Plus, Silver Plus or Gold Plus plan you are eligible for the fitness reimbursement which provides access to a qualified fitness program.

• Health Exchange Plus Plan Fitness Reimbursement- Texas (PDF)
• Health Exchange Plus Plan Fitness Reimbursement- Louisiana (PDF)

• Glossary of Terms (PDF)
• Online Glossary of Terms

• Payment Authorization Form (PDF)

Provider & Pharmacy Directory

ENGLISH

• 2023/2024 Louisiana Provider & Pharmacy Directory (PDF)
• 2023/2024 Texas Provider & Pharmacy Directory (PDF)

SPANISH

• 2023/2024 Louisiana Provider & Pharmacy Directory (PDF)
• 2023/2024 Texas Provider & Pharmacy Directory (PDF)

Provider Search Tool

• Online Searchable Provider Directories

• Medical Reimbursement Form

• RX Claim Form (PDF)

• Transplant Travel Claim Form