Prospective Member Communication
Sendero Health Plans has procedures to guide us in making decisions about using your health care benefits. Our goal is to assure that you use your benefits appropriately in an efficient, quality-driven, cost-effective manner.
For some services such as physical therapy, speech therapy, chiropractic care there may be a defined number of visits per year. Many services have a copayment amount.
Sendero Health Plans has a Network of participating providers. These providers have contracted with us to treat our members. There are many different types of providers in our Network so that all of your health care needs can be met.
If you seek care and services from a provider who is not in Sendero’s Network, without a referral, you will have to pay for those services.
When Sendero helps to arrange non-emergency services for you outside its service area, we will cover the cost. If you obtain out of service care without our help, you will be responsible to pay for those services.
Sendero does not cover care provided when you are out of the country. You will have to pay for all medical services received in a foreign country.
For more information about our utilization procedures, our provider and practitioner network and potential network, service or benefit restrictions, please contact Customer Services at 1-800-791-6511 or 512-593-6227. We will provide our Provider Directory and schedule of benefits, upon request.
Practitioner and Provider Availability
Approval for Services
Many services require approval before you can receive the service. This is called pre-service approval. For example inpatient hospital care that is not an emergency requires approval. This means your physician must call us for approval prior to admitting you to the hospital. It is the physician’s responsibility to obtain approval for services when indicated. If approval is not granted, the process to appeal the decision will be explained.
Some services do not require pre-service approval. These include:
• Emergency services.
• Family planning services.
• Basic prenatal care in-network.
• Sexually transmitted disease services.
• HIV testing and counseling.
• Office visits to Primary Care Practitioners.
If you are hospitalized or if you are receiving care over a long period of time, we will review your condition on a regular basis to determine if your care continues to be covered. To be covered your care must continually meet criteria for the level of care you are receiving. This process of ongoing review is called concurrent review. Our staff will discuss the status of your condition with your provider. If we do not approve your provider’s request for continued care in the hospital or other setting, the process to appeal the decision will be explained to your provider and to you.
In some cases you may obtain care and ask us to pay for it after you have received the care and services. We will review the situation and make a decision. This is called post-service approval. If the information about the situation does not meet our criteria we will not approve the request for payment. We will tell your provider and you about the process to appeal this decision.
IdealCare maintains a formulary list that tells you which medications are generic, preferred and non-preferred. A copy of the current list can be obtained by calling a Customer Service representative, who also can answer your questions about your copayments. The Sendero Plan Formulary also is posted on the Sendero Plan website at www.senderohealth.com/Senderoformulary. Please note that over-the-counter medications are not a covered benefit and some prescribed medications require prior authorization.
There is little difference between a brand name drug and the generic version. Generic drugs have the same active ingredients as brand name drugs and are less costly. They may be a different color and shape. Your pharmacy will fill your prescription with a generic drug if it is available. Food and Drug Administration (FDA) requires generic drugs to have the same high quality, strength, purity and stability as brand-name drugs. If your provider does not want a generic substitution, he or she must contact us and tell us the reason. If we do not approve the request, you and/or your provider will be informed of our decision. You have the right to request an appeal if the request is not approved. We will tell you how to do this when we give you or your provider our decision.
For some drugs, our approval is required. This is called prior authorization. If your provider decides that you should take a drug in this group, he or she will contact us to receive authorization before giving you a prescription for the drug.
Your provider must complete a prior authorization form and send it to us so that a decision about coverage can be reached. After the request is reviewed, you and/or your provider will be informed of our decision. If we approve the drug, you may obtain it from a participating pharmacy. If we do not approve the request, you and/or your provider will be informed of our decision. You have the right to request an appeal if the request is not approved. We will tell you how to do this when we give you our decision.
You have different coverage levels, depending on what ‘tier’ drug you are assigned to on the Sendero Plan pharmacy formulary. With a five-level drug benefit, your prescription medications fall into one of the five categories or ‘tiers’. Each tier has a different copay or coinsurance. Refer to your Summary of Benefits and Coverage and your Evidence of Coverage for additional details or contact Customer Service toll-free at .
Some drugs require step therapy. This means that you must try a first step drug before the second step drug will be covered. Usually generic drugs are in the first step.
You may be asked to take a drug that is chemically different from the drug originally prescribed. This different drug will have the same therapeutic purpose and will be used for the same FDA approved conditions. This is called Therapeutic Interchange. The pharmacist or your prescriber may ask you to take this drug and will explain the reasons why he or she believes this is a better drug choice for you. You do not have to agree. If you do not agree, your original drug prescription will be filled.
• Preventative care drugs for qualified enrollees; Zero copay.
• Tier 1 – Most affordable drugs, including most generics and select branded drugs; lowest copay.
• Tier 2 – Preferred drugs – drugs are designated preferred because they have been proven to be effective and may be favorably priced compared to other drugs that treat the same condition; Middle-level copay.
• Tier 3 – Non-preferred drugs – non-preferred drugs have not been found to be any more cost effective than available generics or preferred band; Higher copay.
• Specialty Drug (SP) – Specialty drugs – typically requires special dispensing, and has limited availability and patient populations; Highest coinsurance.
All medication is dispensed on a 30 day supply; mail order is not available for Sendero members.
We encourage safe use of drugs by setting a maximum quantity per month for some drugs. These quantity limits are based on the (FDA) guidelines and the manufacturer’s recommendations. There are circumstances that warrant exceptions to these limits. Your physician can request an exception by contacting us and telling us the reason for the exception. We will inform you about our decision. If we do not approve the request for an exception to the quantity limits, we will tell your physician how to appeal the decision.
For more information about our pharmacy procedures and to see if a drug is included in our formulary, click here www.senderohealth.com/Senderoformulary. The formulary will tell you about:
• The drugs included in our formulary.
• Quantity limits and copayments for drugs.
• Restrictions that apply to drugs such as prior authorization requirements.
• How to obtain prior authorization for a drug, if required.
• How your physician may request an exception to our formulary, including the documentation that we require to review this request.
• How you or your physician may appeal our decision not to approve the request for an exception.
• The process for generic substitution of drugs.
• Step therapy requirements.
• Therapeutic interchange requirements.
• Any other requirements, restrictions, limitations, or incentives that apply to the use of certain drugs.
What is Obamacare/The Affordable Care Act?
Obamacare, officially known as The Affordable Care Act, was signed into law on March 23, 2010. The law significantly reforms our health care system and aims to ensure affordable health coverage is available to those who don't receive it through an employer. The law mandates that Americans must purchase health insurance, but some people will qualify to get help paying for it if they meet certain criteria. The majority of the reforms begin in 2014, though it won't be completely rolled out until 2022.