Silver Plan #2 - Sendero Health Plans

Sendero Health Plans: IdealCare Silver Two Coverage Period: 1/1/2014 – 12/31/2014Summary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage for: Individual; Individual+Family| Plan Type: HMOCommonMedical EventServices You May NeedYour Cost IfYou Use anIn-networkProviderYour Cost IfYou Use anOut-of-networkProviderGlasses No Charge Not CoveredDental check-up Not Covered Not CoveredLimitations & ExceptionsLimited to 1 pair of glasses (framesand lenses) per year.No coverage for out-of-networkservices.Benefits available through a separatedental offering.Excluded Services & Other Covered Services:Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)• Accidental Dental • Acupuncture • Bariatric Surgery• Cosmetic Surgery – except as determined tobe medically necessary for treatment or injury• Long-Term/Custodial Nursing Home Care• Out-of-Network Services – except asdetermined to be medically necessary• Dental Care (Adults) • Dental Care (Children)• Non-emergency Care While TravelingOutside of the United States• Orthodontia• Private Duty Nursing • Weight Loss ProgramsOther Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for theseservices.)• Chiropractic Care – limited to 35 visits peryear combined habilitation/rehabilitation(Physical Therapy, Occupational Therapy,Speech Therapy, and Chiropractic Services)• Hearing Aids – limited to 1 every 3 years• Infertility – limited to diagnostic services.Treatment such as in vitro fertilization,artificial insemination and are excluded fromcoverage• Routine Foot Care: limited to foot care in • Routine Eye Care (Adult) – limited to 1 examconnection with diabetes, circulatory disorders per year• Substance use disorder, outpatient servicesQuestions: Call 1-855-526-7388 or visit us at www.senderohealth.com/idealcarebenefits.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary6 of 10at www.cciio.cms.gov or call 1-855-526-7388 to request a copy.

Sendero Health Plans: IdealCare Silver Two Coverage Period: 1/1/2014 – 12/31/2014Coverage ExamplesCoverage for: Individual; Individual+Family| Plan Type: HMOAbout these CoverageExamples:These examples show how this plan might covermedical care in given situations. Use theseexamples to see, in general, how much financialprotection a sample patient might get if they arecovered under different plans.This isnot a costestimator.Don’t use these examples toestimate your actual costsunder this plan. The actualcare you receive will bedifferent from theseexamples, and the cost ofthat care will also bedifferent.See the next page forimportant information aboutthese examples.Having a baby(normal delivery)• Amount owed to providers: $7,540• Plan pays $7,540• Patient pays $0Sample care costs:Hospital charges (mother) $2,700Routine obstetric care $2,100Hospital charges (baby) $900Anesthesia $900Laboratory tests $500Prescriptions $200Radiology $200Vaccines, other preventive $40Total $7,540Patient pays:Deductibles $0Copays $0Coinsurance $0Limits or exclusions $0Total $0Managing type 2 diabetes(routine maintenance ofa well-controlled condition)• Amount owed to providers: $5,400• Plan pays $5,400• Patient pays $0Sample care costs:Prescriptions $2,900Medical Equipment and Supplies $1,300Office Visits and Procedures $700Education $300Laboratory tests $100Vaccines, other preventive $100Total $5,400Patient pays:Deductibles $0Copays $0Coinsurance $0Limits or exclusions $0Total $0Questions: Call 1-855-526-7388 or visit us at www.senderohealth.com/idealcarebenefits.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.cciio.cms.gov or call 1-855-526-7388 to request a copy.9 of 10