Sendero Health Original Silver / $20 PCP / $10 Gen Rx – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $20 copay
Specialist visit: $60 copay after deductible
Urgent care visit: $60 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $4,250 per person $4,250 per person |
| Out-of-pocket max | $8,050 per person $16,100 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $20 copay |
| Specialist visit | $60 copay after deductible |
| Preventive care visit | No data available |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $60 copay |
| Emergency room | $350 copay after deductible |
| Ambulance | $350 copay after deductible |
| Hospital stay (facility) | $500 copay per Stay after deductible |
| Hospital stay (physician) | 30% coinsurance after deductible |
| Outpatient procedure (facility) | 40% coinsurance after deductible |
| Outpatient procedure (physician) | 40% coinsurance after deductible |
| Physical rehabilitation | $60 copay after deductible |
Maternitowny and Pregnancy
| Well baby care | No data available |
| Labor, delivery, hospital stay | $500 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | $40 copay after deductible |
| Non-preferred Brand | $80 copay after deductible |
| Specialty | 30% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $30 copay after deductible |
| Imaging (CT/PET/MRI) | 25% coinsurance after deductible |
| Blood work | 25% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 25% coinsurance after deductible |
| Psychiatric hospital stay | $500 copay per Stay after deductible |
Health Plan Provider Information
| Health Plan Benefits | http://senderohealth.com/files/2024/71837TX001000101.pdf |
| Drug and medication plan formulary | https://senderohealth.com/files/2024/Formulary.pdf |
| Search doctor list | https://www.senderohealth.com/dbsearch/menu_new |
