Sendero Health Capital Silver / $40 PCP / $80 Specialist / $20 Generic Drugs - 71837TX0010017 Health Insurance Plan
Sendero Health Plans, Inc. health insurance plan with the Plan ID 71837TX0010017. The plan is called Sendero Health Capital Silver / $40 PCP / $80 Specialist / $20 Generic Drugs.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 87.33% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 12.67% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 71837TX0010017 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Texas | ||||||||||||||||||
| Health Insurance Issuer | Sendero Health Plans, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 71837TX0010017-05 | ||||||||||||||||||
| Provider Network(s) | NON-PREFERRED PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 17 Dec 2024 06:12 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 71837TX0010017-00 Standard On Exchange Plan - 71837TX0010017-01 Open to Indians below 300% FPL - 71837TX0010017-02 Open to Indians above 300% FPL - 71837TX0010017-03 73% AV Silver Plan - 71837TX0010017-04 |
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| Last Plan Update Date | Wed, 14 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 17 Dec 2024 06:12 GMT |
Benefits of Sendero Health Capital Silver / $40 PCP / $80 Specialist / $20 Generic Drugs Health Insurance Plan, 71837TX0010017-05
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Autism Spectrum Disorders
Same as Habilitation services above |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Brain Injury
Habilitation and Mental/ Behavioral health OP treatment related to Brain injury and acquired brain injury |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Cardiovascular Disease
Atherosclerosis and abnormal artery structure screening for diabetic enrollees and certain enrollees who have a documented medical risk of developing coronary heart disease |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Chemotherapy
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 35.0 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic. |
YES | $60.00 Copay after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section. |
YES | $300.00 Copay after deductible |
|
| Dental Check-Up for Children
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Diabetes Care Management
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Diabetes Education
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Benefit consists of 1 pair of glasses (frames with lenses) per calendar year |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
|
YES | $10.00 |
100.00% |
| Habilitation Services
|
YES | $20.00 |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years Exclusions: Benefit consists of 1 hearing aid every 3 calendar years To restore or correction of impaired speech or hearing loss. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year Exclusions: No limit on private duty nursing when medically necessary. |
YES | No Charge |
100.00% |
| Hospice Services
Preauthorization is required. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Inherited Metabolic Disorder - PKU
Amnio acid-based formulas only |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Preauthorization is required. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Mammography
Including 2D and 3D (breast tomosynthesis) for women age 35 and older on an annual basis |
YES | $250.00 Copay after deductible, No Charge |
100.00% |
| Mental/Behavioral Health Inpatient Services
Preauthorization is required. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Preauthorization is required. |
YES | $20.00 |
100.00% |
| Mental Health Other
Clinically-based mental/nervous disorders |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Non-Preferred Brand Drugs
|
YES | $60.00 Copay after deductible |
100.00% |
| Nutritional Counseling
|
YES | ||
| Off Label Prescription Drugs
Off label drugs |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Osteoporosis
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $10.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Pediatric Services Other
reconstructive surgery for craniofacial abnormalities in a child |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Post-Mastectomy Care
Mastecctomy or lymp node dissection, minimus stay |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $20.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | $10.00 |
100.00% |
| Prescription Drugs Other
Oral anticancer medications |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
This category also applies to mental health, substance abuse office visits |
YES | $20.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Replacement Prosthetic Appliances except those necessitated by growth due to maturity of the participant. Also, prosthetics provided for the treatment of the temporomandibular joint and all adjacent or related muscles and nerves. Medically necessary foot orthotics are not subject to a calendar year maximum. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed. |
YES | 20.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
|
YES | $20.00 |
100.00% |
| Rehabilitative Speech Therapy
|
YES | $20.00 |
|
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | $30.00 |
100.00% |
| Routine Foot Care
Excluded for any services or supplies in connection with routine foot care, including the removal of warts, corns, or calluses, or the cutting and trimming of toenails, in the absence of diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency. |
YES | ||
| Skilled Nursing Facility
Limit: 25.0 Visit(s) per Year |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $40.00 |
100.00% |
| Specialty Drugs
|
YES | $250.00 Copay after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Preauthorization is required. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Certain services require preauthorization. |
YES | $20.00 |
100.00% |
| Transplant
Preauthorization is required. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Transplant Donor Coverage
Exclusions: Donor expenses for a Participant in connection with an organ and tissue transplant if the recipient is not covered under this Plan. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Any non-surgical (dental restorations, orthodontics, or physical therapy) or non-diagnostic services or supplies (oral appliances, oral splints, oral orthotics, devices, or prosthetics) provided for the treatment of the temporomandibular joint and all adjacent or related muscles and nerves.Though state law only mandates coverage for temporomandibular joint (TMJ) disorders for large group plans and HMOs, the benchmark plan covers TMJ. Therefore, it is considered part of the EHB package for Texas. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $30.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 30.00% Coinsurance after deductible |
0.00% |
Sendero Health Capital Silver 87 / $20 PCP / $40 Specialist / $10 Generic Drugs Health Insurance Plan Variant 71837TX0010017-05 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.8733413803485369 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | 87% AV Level Silver Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| Disease Management Programs Offered | Asthma, Depression, Diabetes |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | TXF002 |
| Formulary URL | URL |
| HIOS Product ID | 71837TX001 |
| Import Date | 2024-08-14 01:01:35 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | Yes |
| Is a Referral Required for Specialist? | Yes |
| Issuer ID | 71837 |
| Issuer Marketplace Marketing Name | Sendero Health Plans, Local Nonprofit |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | TXN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 71837TX0010017-05 |
| Plan Marketing Name | Sendero Health Capital Silver / $40 PCP / $80 Specialist / $20 Generic Drugs |
| Plan Type | HMO |
| Plan Variant Marketing Name | Sendero Health Capital Silver 87 / $20 PCP / $40 Specialist / $10 Generic Drugs |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,500 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $500 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $600 |
| SBC Scenario, Having Diabetes, Deductible | $100 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | TXS001 |
| Source Name | HIOS |
| Specialist Requiring a Referral | Cardiology, Cardiovascular (Heart, Blood Vessels),ENT (Ears, Nose, Throat),Hematology (Blood),Oncology (Cancer),Otology (Ears),Genetics (Inherited Diseases, Birth Defects),Pulmonology (Lungs, Breathing),Gastroenterology (Stomach, Digestion),Neurology (Brain, Nervous System), Allergist (Allergies),Chiropractor (Bones, Joints),Rheumatologist (Joints, Muscles, Tendons),Urology (Urinary Tract),Surgery (Operations),Radiology (X-Rays),Podiatry (Feet, Toenails),Optometrist (Eyes, Glasses),Otolaryngology (Ear, Nose, and Throat),Orthopedics (Bones and Joints),Ophthalmology (Eyes), Neurosurgery (Operations of the Brain, Spinal Cord),Nuclear Medicine (Testing, e.g.,. MRI, CAT scan),Nephrology (Kidney), Endocrinology (Glands),Dermatology (Skin),Cardiothoracic Surgery (Operations of the Heart and Chest),Ambulatory Medicine (General Non-emergency Care),Immunology (Immune System),Infectious Diseases (Viral/Bacterial Infections),Neonatology/Perinatology (Fetus and Newborns),Oral-Maxillofacial Surgery (Jaw and Mouth),Physical Medicine (Rehabilitation),Plastic Surgery (Corrective Surgery),Retrovirology (Viral Diseases, AIDS),Adolescent Medicine (Teenagers),Sports Medicine (Sports Injuries),Nutrition/GI (Eating, Digestion),Colon/Rectal Surgery (Bowels),Thoracic Surgery (Chest Surgery),Hepatology (Liver),Vascular Surgery (Operations of the Blood Vessels) |
| Plan ID | 71837TX0010017 |
| State Code | TX |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $6000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $3000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $3,000 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $1000 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $500 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $500 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 30.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $1000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $500 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $6000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $3000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $3,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Sendero Health Capital Silver / $40 PCP / $80 Specialist / $20 Generic Drugs Health Insurance Plan, 71837TX0010017
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Sendero Health Capital Silver / $40 PCP / $80 Specialist / $20 Generic Drugs, 71837TX0010017 Health Insurance Plan, 71837TX0010017
-
Does Sendero Health Capital Silver / $40 PCP / $80 Specialist / $20 Generic Drugs Health Insurance Plan, 71837TX0010017 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (71837TX0010017) Health Insurance Plan, Variant (71837TX0010017-05) offer Disease Management Programs?
Does (71837TX0010017) Health Insurance Plan, Variant (71837TX0010017-05) have Out Of Country Coverage?
Does (71837TX0010017) Health Insurance Plan, Variant (71837TX0010017-05) have Out of Service Area Coverage?
Does (71837TX0010017) Health Insurance Plan, Variant (71837TX0010017-05) offer Disease Management Programs?
Does Sendero Health Capital Silver 87 / $20 PCP / $40 Specialist / $10 Generic Drugs Health Insurance Plan, Variant (71837TX0010017-05) offer Disease Management Programs for Asthma?
Does Sendero Health Capital Silver 87 / $20 PCP / $40 Specialist / $10 Generic Drugs Health Insurance Plan, Variant (71837TX0010017-05) offer Disease Management Programs for Depression?
Does Sendero Health Capital Silver 87 / $20 PCP / $40 Specialist / $10 Generic Drugs Health Insurance Plan, Variant (71837TX0010017-05) offer Disease Management Programs for Diabetes?
Disclaimer: This is based on the import(Date: Tue, 17 Dec 2024 06:12 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API