BSW Prime Silver HMO 005
40788TX0460005
Silver
HMO
BSW Prime Silver HMO 005 is a Silver HMO plan by Baylor Scott and White Health Plan.
IMPORTANT: You are viewing the 2024 version of BSW Prime Silver HMO 005 40788TX0460005. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.
Locations
BSW Prime Silver HMO 005 is offered in the following counties.
Plan Overview
This is a plan overview for 2024 version of BSW Prime Silver HMO 005 40788TX0460005.
| Insurer: | Baylor Scott and White Health Plan |
| Network Type: | HMO |
| Metal Type: | Silver |
| HSA Eligible?: | No |
| Plan ID: | 40788TX0460005 |
Cost-Sharing Overview
BSW Prime Silver HMO 005 offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for BSW Prime Silver HMO 005 includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $9450 per person | $18900 per group |
| Deductible: | $1200 per person | $2400 per group |
| Coinsurance: | 30.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for BSW Prime Silver HMO 005 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: | $1,200.00 |
| Copayment: | $2,500.00 |
| Coinsurance: | $300.00 |
| Limit: | $60.00 |
| Deductible: | $0.00 |
| Copayment: | $1,000.00 |
| Coinsurance: | $90.00 |
| Limit: | $20.00 |
| Deductible: | $1,200.00 |
| Copayment: | $500.00 |
| Coinsurance: | $70.00 |
| 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 BSW Prime Silver HMO 005?
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
BSW Prime Silver HMO 005 offers the following features and referral requirements.
| Wellness Program: | No |
| Disease Program: | Asthma, Heart Disease, Diabetes, Pregnancy |
| Notice Pregnancy: | No |
| Referral Specialist: | No |
| Specialist Requiring Referral: | |
| Plan Exclusions: | |
| Child Only Option?: | Allows Adult and Child-Only |
Network Details
The following network details will help you understand what BSW Prime Silver HMO 005 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: | Emergency Only |
| National Network: | No |
Additional Benefits and Cost-Sharing
BSW Prime Silver HMO 005 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 | $45.00 Not Applicable | Not Applicable 100.00% | Covered at no cost for dependent members through the age of 18. |
| Specialist Visit Covered | $85.00 Not Applicable | Not Applicable 100.00% | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $45.00 Not Applicable | Not Applicable 100.00% | Covered at no cost for dependent members through the age of 18. |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | $1000.00 Copay after deductible Not Applicable | Not Applicable 100.00% | |
| Outpatient Surgery Physician/Surgical Services Covered | $250.00 Copay after deductible Not Applicable | 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 | Diagnosis covered but treatment not covered. | ||
| Long-Term/Custodial Nursing Home Care Not Covered | |||
| Private-Duty Nursing Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 100.00% | When pre-approved in a limited set of circumstances under the Home Health Care benefit. Refer to plan document. |
| Routine Eye Exam (Adult) Not Covered | |||
| Urgent Care Centers or Facilities Covered | $85.00 Not Applicable | $85.00 Not Applicable | |
| Home Health Care Services Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 100.00% | 60.0 Days per Year |
| Emergency Room Services Covered | $750.00 Copay after deductible Not Applicable | $750.00 Copay after deductible Not Applicable | |
| Emergency Transportation/Ambulance Covered | $750.00 Copay after deductible Not Applicable | $750.00 Copay after deductible Not Applicable | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | $2000.00 Copay per Stay after deductible Not Applicable | 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 | No Charge Not Applicable | Not Applicable 100.00% | |
| Bariatric Surgery Not Covered | |||
| Cosmetic Surgery Not Covered | Covered only if necessary to improve the function of, or to attempt to create a normal appearance of an abnormal structure caused by congenital defects, developmental deformities, trauma, tumors, infection or disease. | ||
| Skilled Nursing Facility Covered | $2000.00 Copay per Stay after deductible Not Applicable | Not Applicable 100.00% | 25.0 Days per Year |
| Prenatal and Postnatal Care Covered | $45.00 Not Applicable | Not Applicable 100.00% | No charge for prenatal visits; postnatal visits are covered at the PCP office visit copay. |
| Delivery and All Inpatient Services for Maternity Care Covered | $2000.00 Copay after deductible Not Applicable | Not Applicable 100.00% | 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 | $45.00 Not Applicable | Not Applicable 100.00% | Copay applies for office visits. All other outpatient benefits will pay at the same cost share level as any other medical/surgical benefit. Certain services require preauthorization. |
| Mental/Behavioral Health Inpatient Services Covered | $2000.00 Copay per Stay after deductible Not Applicable | Not Applicable 100.00% | Certain services require preauthorization. |
| Substance Abuse Disorder Outpatient Services Covered | $45.00 Not Applicable | Not Applicable 100.00% | Copay applies for office visits. All other outpatient benefits will pay at the same cost share level as any other medical/surgical benefit. Certain services require preauthorization. |
| Substance Abuse Disorder Inpatient Services Covered | $2000.00 Copay per Stay after deductible Not Applicable | Not Applicable 100.00% | Certain services require preauthorization. |
| Generic Drugs Covered | $20.00 Not Applicable | Not Applicable 100.00% | If copay applies, copay amount is for 30 day supply. Copay for 90 day supply is three times the copay for 30 day supply. |
| Preferred Brand Drugs Covered | $100.00 Copay after deductible Not Applicable | Not Applicable 100.00% | If copay applies, copay amount is for 30 day supply. Copay for 90 day supply is three times the copay for 30 day supply. |
| Non-Preferred Brand Drugs Covered | $140.00 Copay after deductible Not Applicable | Not Applicable 100.00% | If copay applies, copay amount is for 30 day supply. Copay for 90 day supply is three times the copay for 30 day supply. |
| Specialty Drugs Covered | $500.00 Copay after deductible Not Applicable | Not Applicable 100.00% | If copay applies, copay amount is for 30 day supply. |
| Outpatient Rehabilitation Services Covered | $45.00 Not Applicable | Not Applicable 100.00% | 35.0 Visit(s) per Year |
| Habilitation Services Covered | $45.00 Not Applicable | Not Applicable 100.00% | 35.0 Visit(s) per Year |
| Chiropractic Care Covered | $45.00 Not Applicable | Not Applicable 100.00% | 35.0 Visit(s) per Year |
| Durable Medical Equipment Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Hearing Aids Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 100.00% | 1.0 Item(s) per 3 Years To restore or correct impaired speech or hearing loss. |
| Imaging (CT/PET Scans, MRIs) Covered | $250.00 Copay after deductible Not Applicable | Not Applicable 100.00% | |
| Preventive Care/Screening/Immunization Covered | No Charge No Charge | Not Applicable 100.00% | |
| Routine Foot Care Not Covered | Not covered 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 | $85.00 Not Applicable | Not Applicable 100.00% | 1.0 Exam(s) per Year |
| Eye Glasses for Children Covered | $85.00 Not Applicable | Not Applicable 100.00% | 1.0 Item(s) per Year 1 pair of glasses (lenses and frames) per year |
| Dental Check-Up for Children Not Covered | |||
| Rehabilitative Speech Therapy Covered | $45.00 Not Applicable | Not Applicable 100.00% | 35.0 Visit(s) per Year |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $45.00 Not Applicable | Not Applicable 100.00% | 35.0 Visit(s) per Year |
| Well Baby Visits and Care Covered | No Charge No Charge | Not Applicable 100.00% | |
| Laboratory Outpatient and Professional Services Covered | $50.00 Copay after deductible Not Applicable | Not Applicable 100.00% | Refer to Plan Document for cost associated with certain outpatient laboratory and professional services. |
| X-rays and Diagnostic Imaging Covered | $125.00 Copay after deductible Not Applicable | Not Applicable 100.00% | Refer to Plan Document for cost associated with certain outpatient laboratory and professional services. |
| Basic Dental Care – Child Not Covered | |||
| Orthodontia – Child Not Covered | |||
| Major Dental Care – Child Not Covered | |||
| 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 30.00% Coinsurance after deductible | Not Applicable 100.00% | Preauthorization is required. |
| Accidental Dental Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Dialysis Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Allergy Testing Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Chemotherapy Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Radiation Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Diabetes Education Covered | $45.00 Not Applicable | Not Applicable 100.00% | |
| Prosthetic Devices Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 100.00% | Medically necessary foot orthotics are not subject to a calendar year maximum. |
| Infusion Therapy Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Treatment for Temporomandibular Joint Disorders Covered | Not Applicable 30.00% Coinsurance after deductible | 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. |
| Nutritional Counseling Covered | $45.00 Not Applicable | Not Applicable 100.00% | Copay waived if provided as preventive care. |
| Reconstructive Surgery Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Gender Affirming Care Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 100.00% | Certain services require preauthorization. |
| Diabetes Care Management Covered | $45.00 Not Applicable | Not Applicable 100.00% | |
| Inherited Metabolic Disorder – PKU Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Off Label Prescription Drugs Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Prescription Drugs Other Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Post-Mastectomy Care Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Brain Injury Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Pediatric Services Other Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Autism Spectrum Disorders Covered | $45.00 Not Applicable | Not Applicable 100.00% | Copay applies for office visits. All other outpatient benefits will pay at the same cost share level as any other medical/surgical benefit. Certain services require preauthorization. |
| Transplant Donor Coverage Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 100.00% |
Free Preventive Services
There is no copayment or coinsurance for any of the following BSW Prime Silver HMO 005 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 BSW Prime Silver HMO 005 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 BSW Prime Silver HMO 005?
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