Sendero Health Capital Silver / $40 PCP / $80 Specialist / $20 Gen Rx
71837TX0010017
Silver
HMO
Sendero Health Capital Silver / $40 PCP / $80 Specialist / $20 Gen Rx is a Silver HMO plan by Sendero Health Plans, Local Nonprofit.
IMPORTANT: You are viewing the 2024 version of Sendero Health Capital Silver / $40 PCP / $80 Specialist / $20 Gen Rx 71837TX0010017. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.
Locations
Sendero Health Capital Silver / $40 PCP / $80 Specialist / $20 Gen Rx is offered in the following counties.
Plan Overview
This is a plan overview for 2024 version of Sendero Health Capital Silver / $40 PCP / $80 Specialist / $20 Gen Rx 71837TX0010017.
| Insurer: | Sendero Health Plans, Local Nonprofit |
| Network Type: | HMO |
| Metal Type: | Silver |
| HSA Eligible?: | No |
| Plan ID: | 71837TX0010017 |
Cost-Sharing Overview
Sendero Health Capital Silver / $40 PCP / $80 Specialist / $20 Gen Rx offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Sendero Health Capital Silver / $40 PCP / $80 Specialist / $20 Gen Rx includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $9100 per person | $18200 per group |
| Deductible: | $5900 per person | $11800 per group |
| Coinsurance: | 40.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Sendero Health Capital Silver / $40 PCP / $80 Specialist / $20 Gen Rx will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | per person not applicable | per group not applicable |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $5,900.00 |
| Copayment: | $10.00 |
| Coinsurance: | $1,600.00 |
| Limit: | $0.00 |
| Deductible: | $100.00 |
| Copayment: | $1,100.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
| Deductible: | $1,700.00 |
| Copayment: | $400.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
Notes:
- Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
- You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Sendero Health Capital Silver / $40 PCP / $80 Specialist / $20 Gen Rx?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904
Plan Features
Sendero Health Capital Silver / $40 PCP / $80 Specialist / $20 Gen Rx offers the following features and referral requirements.
| Wellness Program: | Yes |
| Disease Program: | Asthma, Depression, Diabetes |
| Notice Pregnancy: | Yes |
| Referral Specialist: | Yes |
| Specialist Requiring 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 Exclusions: | |
| Child Only Option?: | Allows Adult and Child-Only |
Network Details
The following network details will help you understand what Sendero Health Capital Silver / $40 PCP / $80 Specialist / $20 Gen Rx covers when you are out of the service area or out of the country.
| Out of Country Coverage: | No |
| Out of Country Coverage Description: | |
| Out of Service Area Coverage: | No |
| Out of Service Area Coverage Description: | |
| National Network: | No |
Additional Benefits and Cost-Sharing
Sendero Health Capital Silver / $40 PCP / $80 Specialist / $20 Gen Rx includes the following benefits at the cost sharing rates listed below.
| Service | In-Network Copay / Coinsurance | Out-of-Network Copay / Coinsurance | Limits and Explanation |
|---|---|---|---|
| Primary Care Visit to Treat an Injury or Illness Covered | $40.00 Not Applicable | Not Applicable 100.00% | |
| Specialist Visit Covered | $80.00 Not Applicable | Not Applicable 100.00% | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $20.00 Not Applicable | Not Applicable 100.00% | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Outpatient Surgery Physician/Surgical Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Hospice Services Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 100.00% | Preauthorization is required. |
| Routine Dental Services (Adult) Not Covered | |||
| Infertility Treatment Not Covered | |||
| Long-Term/Custodial Nursing Home Care Not Covered | |||
| Private-Duty Nursing Not Covered | |||
| Routine Eye Exam (Adult) Not Covered | |||
| Urgent Care Centers or Facilities Covered | $60.00 Not Applicable | Not Applicable 100.00% | |
| Home Health Care Services Covered | Not Applicable No Charge | Not Applicable 100.00% | 60.0 Visit(s) per Year No limit on private duty nursing when medically necessary. |
| Emergency Room Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 40.00% Coinsurance after deductible | |
| Emergency Transportation/Ambulance Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 40.00% Coinsurance after deductible | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Preauthorization is required. |
| Inpatient Physician and Surgical Services Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Bariatric Surgery Not Covered | |||
| Cosmetic Surgery Not Covered | |||
| Skilled Nursing Facility Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | 25.0 Visit(s) per Year |
| Prenatal and Postnatal Care Covered | $10.00 Not Applicable | Not Applicable 100.00% | |
| Delivery and All Inpatient Services for Maternity Care Covered | $500.00 Copay after deductible Not Applicable | Not Applicable Not Applicable | Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section. |
| Mental/Behavioral Health Outpatient Services Covered | $40.00 Not Applicable | Not Applicable 100.00% | Preauthorization is required. |
| Mental/Behavioral Health Inpatient Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Preauthorization is required. |
| Substance Abuse Disorder Outpatient Services Covered | $40.00 Not Applicable | Not Applicable 100.00% | Certain services require preauthorization. |
| Substance Abuse Disorder Inpatient Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Preauthorization is required. |
| Generic Drugs Covered | $20.00 Not Applicable | Not Applicable 100.00% | |
| Preferred Brand Drugs Covered | $40.00 Not Applicable | Not Applicable 100.00% | |
| Non-Preferred Brand Drugs Covered | $80.00 Copay after deductible Not Applicable | Not Applicable 100.00% | |
| Specialty Drugs Covered | $350.00 Copay after deductible Not Applicable | Not Applicable 100.00% | |
| Outpatient Rehabilitation Services Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | |
| Habilitation Services Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | |
| Chiropractic Care Covered | $60.00 Copay after deductible Not Applicable | Not Applicable 100.00% | 35.0 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic. |
| Durable Medical Equipment Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | |
| Hearing Aids Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | 1.0 Item(s) per 3 Years Benefit consists of 1 hearing aid every 3 calendar years To restore or correction of impaired speech or hearing loss. |
| Imaging (CT/PET Scans, MRIs) Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Preventive Care/Screening/Immunization Covered | Not Applicable 0.00% | Not Applicable 100.00% | |
| Routine Foot Care Covered | Not Applicable Not Applicable | Not Applicable Not Applicable | 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. |
| Acupuncture Not Covered | |||
| Weight Loss Programs Not Covered | |||
| Routine Eye Exam for Children Covered | $45.00 Not Applicable | Not Applicable 100.00% | 1.0 Visit(s) per Year |
| Eye Glasses for Children Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | 1.0 Item(s) per Year Benefit consists of 1 pair of glasses (frames with lenses) per calendar year |
| Dental Check-Up for Children Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | |
| Rehabilitative Speech Therapy Covered | $40.00 Not Applicable | Not Applicable Not Applicable | |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $40.00 Not Applicable | Not Applicable 100.00% | |
| Well Baby Visits and Care Covered | No Charge Not Applicable | Not Applicable 100.00% | |
| Laboratory Outpatient and Professional Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| X-rays and Diagnostic Imaging Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Basic Dental Care – Child Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | |
| Orthodontia – Child Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | |
| Major Dental Care – Child Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | |
| Basic Dental Care – Adult Not Covered | |||
| Orthodontia – Adult Not Covered | |||
| Major Dental Care – Adult Not Covered | |||
| Abortion for Which Public Funding is Prohibited Not Covered | |||
| Transplant Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | Preauthorization is required. |
| Accidental Dental Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | |
| Dialysis Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | |
| Allergy Testing Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | |
| Chemotherapy Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | |
| Radiation Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | |
| Diabetes Education Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | |
| Prosthetic Devices Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | 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. |
| Infusion Therapy Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | |
| Treatment for Temporomandibular Joint Disorders Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | 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. |
| Nutritional Counseling Covered | Not Applicable Not Applicable | Not Applicable Not Applicable | |
| Reconstructive Surgery Covered | Not Applicable 30.00% | Not Applicable 100.00% | Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed. |
| Gender Affirming Care Not Covered | |||
| Mammography Covered | $250.00 Copay after deductible No Charge | Not Applicable 100.00% | Including 2D and 3D (breast tomosynthesis) for women age 35 and older on an annual basis |
| Cardiovascular Disease Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | Atherosclerosis and abnormal artery structure screening for diabetic enrollees and certain enrollees who have a documented medical risk of developing coronary heart disease |
| Osteoporosis Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | |
| Diabetes Care Management Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | |
| Inherited Metabolic Disorder – PKU Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | Amnio acid-based formulas only |
| Off Label Prescription Drugs Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | Off label drugs |
| Mental Health Other Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | Clinically-based mental/nervous disorders |
| Prescription Drugs Other Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | Oral anticancer medications |
| Post-Mastectomy Care Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | Mastecctomy or lymp node dissection, minimus stay |
| Brain Injury Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | Habilitation and Mental/ Behavioral health OP treatment related to Brain injury and acquired brain injury |
| Pediatric Services Other Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | reconstructive surgery for craniofacial abnormalities in a child |
| Transplant Donor Coverage Covered | Not Applicable 20% Coinsurance after deductible | Not Applicable 100.00% | Donor expenses for a Participant in connection with an organ and tissue transplant if the recipient is not covered under this Plan. |
| Autism Spectrum Disorders Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | Same as Habilitation services above |
Free Preventive Services
There is no copayment or coinsurance for any of the following Sendero Health Capital Silver / $40 PCP / $80 Specialist / $20 Gen Rx preventive services. This is true even if you haven’t met your yearly deductible.
Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for Sendero Health Capital Silver / $40 PCP / $80 Specialist / $20 Gen Rx including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.
| Summary of Benefits: | Summary of Benefits Link |
| Plan Brochure: | Plan Brochure Link |
| Formulary: | Formulary Link |
| Premium Payment Website: | Premium Payment Link |
Ready to sign up for Sendero Health Capital Silver / $40 PCP / $80 Specialist / $20 Gen Rx?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904