Sendero Health Hill Country Gold / $30 PCP / $60 Specialist / $15 Generic Drugs - 71837TX0010018 Health Insurance Plan

Sendero Health Plans, Inc. health insurance plan with the Plan ID 71837TX0010018. The plan is called Sendero Health Hill Country Gold / $30 PCP / $60 Specialist / $15 Generic Drugs.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 71837TX0010018
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 71837TX0010018-02
Provider Network(s) NON-PREFERRED PREFERRED
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 24 Dec 2024 06:21 GMT).

Providers Texas All US States
All 7629 8991
PCP 960 1121
Allergy 6 7
OB/GYN 47 57
Dentists 6 6
Available Variants of the Health Plan

Standard Off Exchange Plan - 71837TX0010018-00

Standard On Exchange Plan - 71837TX0010018-01

Open to Indians below 300% FPL - 71837TX0010018-02

Open to Indians above 300% FPL - 71837TX0010018-03

Last Plan Update Date Wed, 14 Aug 2024 00:00 GMT
Last Import Date Tue, 24 Dec 2024 06:21 GMT

Benefits of Sendero Health Hill Country Gold / $30 PCP / $60 Specialist / $15 Generic Drugs Health Insurance Plan, 71837TX0010018-02

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

$0.00, 0.00%

100.00%
Acupuncture
NO
Allergy Testing
YES

$0.00, 0.00%

100.00%
Autism Spectrum Disorders

Same as Habilitation services above

YES

$0.00, 0.00%

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
YES

$0.00, 0.00%

100.00%
Brain Injury

Habilitation and Mental/ Behavioral health OP treatment related to Brain injury and acquired brain injury

YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Chemotherapy
YES

$0.00, 0.00%

100.00%
Chiropractic Care

Limit: 35.0 Visit(s) per Year

Limited to combined 35 visits per year, including Chiropractic.

YES

$0.00, 0.00%

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

$0.00

$0.00
Dental Check-Up for Children
YES

$0.00, 0.00%

100.00%
Diabetes Care Management
YES

$0.00, 0.00%

100.00%
Diabetes Education
YES

$0.00, 0.00%

100.00%
Dialysis
YES

$0.00, 0.00%

100.00%
Durable Medical Equipment
YES

$0.00, 0.00%

100.00%
Emergency Room Services
YES

$0.00, 0.00%

$0.00, 0.00%
Emergency Transportation/Ambulance
YES

$0.00

$0.00
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

$0.00, 0.00%

100.00%
Gender Affirming Care
NO
Generic Drugs
YES

$0.00, 0.00%

100.00%
Habilitation Services
YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Home Health Care Services

Limit: 60.0 Visit(s) per Year

Exclusions: No limit on private duty nursing when medically necessary.

YES

$0.00, 0.00%

100.00%
Hospice Services

Preauthorization is required.

YES

$0.00, 0.00%

100.00%
Imaging (CT/PET Scans, MRIs)
YES

$0.00, 0.00%

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

$0.00, 0.00%

100.00%
Inherited Metabolic Disorder - PKU

Amnio acid-based formulas only

YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Inpatient Physician and Surgical Services
YES

$0.00, 0.00%

100.00%
Laboratory Outpatient and Professional Services
YES

$0.00, 0.00%

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
YES

$0.00, 0.00%

100.00%
Mammography

Including 2D and 3D (breast tomosynthesis) for women age 35 and older on an annual basis

YES

$0.00, 0.00%

100.00%
Mental/Behavioral Health Inpatient Services

Preauthorization is required.

YES

$0.00, 0.00%

100.00%
Mental/Behavioral Health Outpatient Services

Preauthorization is required.

YES

$0.00, 0.00%

100.00%
Mental Health Other

Clinically-based mental/nervous disorders

YES

$0.00, 0.00%

100.00%
Non-Preferred Brand Drugs
YES

$0.00, 0.00%

100.00%
Nutritional Counseling
YES

$0.00

$0.00
Off Label Prescription Drugs

Off label drugs

YES

$0.00, 0.00%

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
YES

$0.00, 0.00%

100.00%
Osteoporosis
YES

$0.00, 0.00%

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$0.00, 0.00%

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

$0.00, 0.00%

100.00%
Outpatient Rehabilitation Services
YES

$0.00, 0.00%

100.00%
Outpatient Surgery Physician/Surgical Services
YES

$0.00, 0.00%

100.00%
Pediatric Services Other

reconstructive surgery for craniofacial abnormalities in a child

YES

$0.00, 0.00%

100.00%
Post-Mastectomy Care

Mastecctomy or lymp node dissection, minimus stay

YES

$0.00, 0.00%

100.00%
Preferred Brand Drugs
YES

$0.00, 0.00%

100.00%
Prenatal and Postnatal Care
YES

$0.00, 0.00%

100.00%
Prescription Drugs Other

Oral anticancer medications

YES

$0.00, 0.00%

100.00%
Preventive Care/Screening/Immunization
YES

$0.00, 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

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Radiation
YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
YES

$0.00, 0.00%

100.00%
Rehabilitative Speech Therapy
YES

$0.00

$0.00
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Year

YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Specialist Visit
YES

$0.00, 0.00%

100.00%
Specialty Drugs
YES

$0.00, 0.00%

100.00%
Substance Abuse Disorder Inpatient Services

Preauthorization is required.

YES

$0.00, 0.00%

100.00%
Substance Abuse Disorder Outpatient Services

Certain services require preauthorization.

YES

$0.00, 0.00%

100.00%
Transplant

Preauthorization is required.

YES

$0.00, 0.00%

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

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Urgent Care Centers or Facilities
YES

$0.00, 0.00%

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

$0.00, 0.00%

100.00%
X-rays and Diagnostic Imaging
YES

$0.00, 0.00%

$0.00, 0.00%

Sendero Health Hill Country Gold ZCS / $0 PCP / $0 Specialist / $0 Generic Drugs Health Insurance Plan Variant 71837TX0010018-02 Attributes

Plan Attribute Value
AV Calculator Output Number 1.0
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 Zero Cost Sharing Plan Variation
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 TXF003
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 Gold
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) 71837TX0010018-02
Plan Marketing Name Sendero Health Hill Country Gold / $30 PCP / $60 Specialist / $15 Generic Drugs
Plan Type HMO
Plan Variant Marketing Name Sendero Health Hill Country Gold ZCS / $0 PCP / $0 Specialist / $0 Generic Drugs
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $0
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $0
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
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 71837TX0010018
State Code TX
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $0
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $0
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $0
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $0
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $0
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $0
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 Hill Country Gold / $30 PCP / $60 Specialist / $15 Generic Drugs Health Insurance Plan, 71837TX0010018

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Sendero Health Hill Country Gold / $30 PCP / $60 Specialist / $15 Generic Drugs, 71837TX0010018 Health Insurance Plan, 71837TX0010018

  • Does Sendero Health Hill Country Gold / $30 PCP / $60 Specialist / $15 Generic Drugs Health Insurance Plan, 71837TX0010018 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (71837TX0010018) Health Insurance Plan, Variant (71837TX0010018-02) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Depression, Diabetes

    Does (71837TX0010018) Health Insurance Plan, Variant (71837TX0010018-02) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (71837TX0010018) Health Insurance Plan, Variant (71837TX0010018-02) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan).

    Does (71837TX0010018) Health Insurance Plan, Variant (71837TX0010018-02) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Depression, Diabetes

    Does Sendero Health Hill Country Gold ZCS / $0 PCP / $0 Specialist / $0 Generic Drugs Health Insurance Plan, Variant (71837TX0010018-02) offer Disease Management Programs for Asthma?

    Yes, the Sendero Health Hill Country Gold ZCS / $0 PCP / $0 Specialist / $0 Generic Drugs Health Insurance Plan Variant 71837TX0010018-02 offers Disease Management Program for Asthma.

    Does Sendero Health Hill Country Gold ZCS / $0 PCP / $0 Specialist / $0 Generic Drugs Health Insurance Plan, Variant (71837TX0010018-02) offer Disease Management Programs for Depression?

    Yes, the Sendero Health Hill Country Gold ZCS / $0 PCP / $0 Specialist / $0 Generic Drugs Health Insurance Plan Variant 71837TX0010018-02 offers Disease Management Program for Depression.

    Does Sendero Health Hill Country Gold ZCS / $0 PCP / $0 Specialist / $0 Generic Drugs Health Insurance Plan, Variant (71837TX0010018-02) offer Disease Management Programs for Diabetes?

    Yes, the Sendero Health Hill Country Gold ZCS / $0 PCP / $0 Specialist / $0 Generic Drugs Health Insurance Plan Variant 71837TX0010018-02 offers Disease Management Program for Diabetes.

 

Disclaimer: This is based on the import(Date: Tue, 24 Dec 2024 06:21 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