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BSW Prime Silver HMO 008 (Two free PCP visits, $0 Pediatric PCP visit)

40788TX0460008
Silver
HMO

BSW Prime Silver HMO 008 (Two free PCP visits, $0 Pediatric PCP visit) is a Silver HMO plan by Scott and White Health Plan.

IMPORTANT: You are viewing the 2023 version of BSW Prime Silver HMO 008 (Two free PCP visits, $0 Pediatric PCP visit) 40788TX0460008. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

BSW Prime Silver HMO 008 (Two free PCP visits, $0 Pediatric PCP visit) is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of BSW Prime Silver HMO 008 (Two free PCP visits, $0 Pediatric PCP visit) 40788TX0460008.
Insurer: Scott and White Health Plan
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 40788TX0460008

Cost-Sharing Overview

BSW Prime Silver HMO 008 (Two free PCP visits, $0 Pediatric PCP visit) offers the following cost-sharing.

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 008 (Two free PCP visits, $0 Pediatric PCP visit)?

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 008 (Two free PCP visits, $0 Pediatric PCP visit) 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 008 (Two free PCP visits, $0 Pediatric PCP visit) 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 008 (Two free PCP visits, $0 Pediatric PCP visit) 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
$30.00 100.00% Covered at no cost for dependent members through the age of 18.
Specialist Visit
Covered
$70.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$30.00 100.00% Covered at no cost for dependent members through the age of 18.
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
40.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
40.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
40.00% Coinsurance after deductible 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
40.00% Coinsurance after deductible 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
$70.00 $70.00
Home Health Care Services
Covered
40.00% Coinsurance after deductible 100.00%60 Days per Year
Emergency Room Services
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
40.00% Coinsurance after deductible 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
40.00% Coinsurance after deductible 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
40.00% Coinsurance after deductible 100.00%25 Days per Year
Prenatal and Postnatal Care
Covered
$30.00 100.00% No charge for prenatal visits; postnatal visits are covered at the PCP office visit copay.
Delivery and All Inpatient Services for Maternity Care
Covered
40.00% Coinsurance after deductible 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
$30.00 100.00% 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
40.00% Coinsurance after deductible 100.00% Certain services require preauthorization.
Substance Abuse Disorder Outpatient Services
Covered
$30.00 100.00% 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
40.00% Coinsurance after deductible 100.00% Certain services require preauthorization.
Generic Drugs
Covered
$15.00 100.00% 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
$90.00 Copay after deductible 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
$150.00 Copay after deductible 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 100.00% If copay applies, copay amount is for 30 day supply.
Outpatient Rehabilitation Services
Covered
$30.00 100.00%35 Visit(s) per Year
Habilitation Services
Covered
$30.00 100.00%35 Visit(s) per Year
Chiropractic Care
Covered
$30.00 100.00%35 Visit(s) per Year
Durable Medical Equipment
Covered
40.00% Coinsurance after deductible 100.00%
Hearing Aids
Covered
40.00% Coinsurance after deductible 100.00%1 Item(s) per 3 Years To restore or correct impaired speech or hearing loss.
Imaging (CT/PET Scans, MRIs)
Covered
40.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge No Charge 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
$70.00 100.00%1 Exam(s) per Year
Eye Glasses for Children
Covered
$70.00 100.00%1 Item(s) per Year 1 pair of glasses (lenses and frames) per year
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$30.00 100.00%35 Visit(s) per Year
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 100.00%35 Visit(s) per Year
Well Baby Visits and Care
Covered
No Charge No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
40.00% Coinsurance after deductible 100.00% Refer to Plan Document for cost associated with certain outpatient laboratory and professional services.
X-rays and Diagnostic Imaging
Covered
40.00% Coinsurance after deductible 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
40.00% Coinsurance after deductible 100.00% Preauthorization is required.
Accidental Dental
Covered
40.00% Coinsurance after deductible 100.00%
Dialysis
Covered
40.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
40.00% Coinsurance after deductible 100.00%
Chemotherapy
Covered
40.00% Coinsurance after deductible 100.00%
Radiation
Covered
40.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
$30.00 100.00%
Prosthetic Devices
Covered
40.00% Coinsurance after deductible 100.00% Medically necessary foot orthotics are not subject to a calendar year maximum.
Infusion Therapy
Covered
40.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
40.00% Coinsurance after deductible 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
$30.00 100.00% Copay waived if provided as preventive care.
Reconstructive Surgery
Covered
40.00% Coinsurance after deductible 100.00%
Gender Affirming Care
Covered
40.00% Coinsurance after deductible 100.00% Certain services require preauthorization.
Diabetes Care Management
Covered
$30.00 100.00%
Inherited Metabolic Disorder – PKU
Covered
40.00% Coinsurance after deductible 100.00%
Off Label Prescription Drugs
Covered
40.00% Coinsurance after deductible 100.00%
Mental Health Other
Not Covered
Prescription Drugs Other
Covered
40.00% Coinsurance after deductible 100.00%
Post-Mastectomy Care
Covered
40.00% Coinsurance after deductible 100.00%
Brain Injury
Covered
40.00% Coinsurance after deductible 100.00%
Pediatric Services Other
Covered
40.00% Coinsurance after deductible 100.00%
Autism Spectrum Disorders
Covered
$30.00 100.00% 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
40.00% Coinsurance after deductible 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following BSW Prime Silver HMO 008 (Two free PCP visits, $0 Pediatric PCP visit) 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.

Additional Resources

Below are additional resources for BSW Prime Silver HMO 008 (Two free PCP visits, $0 Pediatric PCP visit) 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 008 (Two free PCP visits, $0 Pediatric PCP visit)?

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

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