BSW Prime Silver HMO 005 ($0 deductible, one free PCP visit, $0 Pediatric PCP visit) - 40788TX0460005 Health Insurance Plan

Scott and White Health Plan health insurance plan with the Plan ID 40788TX0460005. The plan is called BSW Prime Silver HMO 005 ($0 deductible, one free PCP visit, $0 Pediatric PCP visit).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.91% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.09% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.

Health Insurance Plan ID 40788TX0460005
Health Insurance Plan Year 2023
State Texas
Health Insurance Issuer Scott and White Health Plan
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 40788TX0460005-00
Provider Network(s) ['TXN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers Texas All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 40788TX0460005-00

Standard On Exchange Plan - 40788TX0460005-01

Open to Indians below 300% FPL - 40788TX0460005-02

Open to Indians above 300% FPL - 40788TX0460005-03

73% AV Silver Plan - 40788TX0460005-04

87% AV Silver Plan - 40788TX0460005-05

94% AV Silver Plan - 40788TX0460005-06

Last Plan Update Date Wed, 25 Jan 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of BSW Prime Silver HMO 005 ($0 deductible, one free PCP visit, $0 Pediatric PCP visit) Health Insurance Plan, 40788TX0460005-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

20.00%

100.00%
Acupuncture
NO
Allergy Testing
YES

20.00%

100.00%
Autism Spectrum Disorders

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.

YES

$45.00

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Brain Injury
YES

20.00%

100.00%
Chemotherapy
YES

20.00%

100.00%
Chiropractic Care

Limit: 35.0 Visit(s) per Year

YES

$45.00

100.00%
Cosmetic Surgery

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.

NO
Delivery and All Inpatient Services for Maternity Care

Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section.

YES

$2,000.00

100.00%
Dental Check-Up for Children
NO
Diabetes Care Management
YES

$45.00

100.00%
Diabetes Education
YES

$45.00

100.00%
Dialysis
YES

20.00%

100.00%
Durable Medical Equipment
YES

20.00%

100.00%
Emergency Room Services
YES

$750.00

$750.00
Emergency Transportation/Ambulance
YES

$750.00

$750.00
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

1 pair of glasses (lenses and frames) per year

YES

$85.00

100.00%
Gender Affirming Care

Certain services require preauthorization.

YES

20.00%

100.00%
Generic Drugs

If copay applies, copay amount is for 30 day supply. Copay for 90 day supply is three times the copay for 30 day supply.

YES

$20.00

100.00%
Habilitation Services

Limit: 35.0 Visit(s) per Year

YES

$45.00

100.00%
Hearing Aids

Limit: 1.0 Item(s) per 3 Years

To restore or correct impaired speech or hearing loss.

YES

20.00%

100.00%
Home Health Care Services

Limit: 60.0 Days per Year

YES

20.00%

100.00%
Hospice Services

Preauthorization is required.

YES

20.00%

100.00%
Imaging (CT/PET Scans, MRIs)
YES

$250.00

100.00%
Infertility Treatment

Diagnosis covered but treatment not covered.

NO
Infusion Therapy
YES

20.00%

100.00%
Inherited Metabolic Disorder - PKU
YES

20.00%

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)

All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Preauthorization is required.

YES

$2000.00 Copay per Stay

100.00%
Inpatient Physician and Surgical Services
YES

No Charge

100.00%
Laboratory Outpatient and Professional Services

Refer to Plan Document for cost associated with certain outpatient laboratory and professional services.

YES

$50.00

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services

Certain services require preauthorization.

YES

$2000.00 Copay per Stay

100.00%
Mental/Behavioral Health Outpatient Services

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.

YES

$45.00

100.00%
Mental Health Other
NO
Non-Preferred Brand Drugs

If copay applies, copay amount is for 30 day supply. Copay for 90 day supply is three times the copay for 30 day supply.

YES

$200.00

100.00%
Nutritional Counseling

Copay waived if provided as preventive care.

YES

$45.00

100.00%
Off Label Prescription Drugs
YES

20.00%

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)

Covered at no cost for dependent members through the age of 18.

YES

$45.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

$1,000.00

100.00%
Outpatient Rehabilitation Services

Limit: 35.0 Visit(s) per Year

YES

$45.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

$250.00

100.00%
Pediatric Services Other
YES

20.00%

100.00%
Post-Mastectomy Care
YES

20.00%

100.00%
Preferred Brand Drugs

If copay applies, copay amount is for 30 day supply. Copay for 90 day supply is three times the copay for 30 day supply.

YES

$100.00

100.00%
Prenatal and Postnatal Care

No charge for prenatal visits; postnatal visits are covered at the PCP office visit copay.

YES

$45.00

100.00%
Prescription Drugs Other
YES

20.00%

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness

Covered at no cost for dependent members through the age of 18.

YES

$45.00

100.00%
Private-Duty Nursing

When pre-approved in a limited set of circumstances under the Home Health Care benefit. Refer to plan document.

YES

20.00%

100.00%
Prosthetic Devices

Medically necessary foot orthotics are not subject to a calendar year maximum.

YES

20.00%

100.00%
Radiation
YES

20.00%

100.00%
Reconstructive Surgery
YES

20.00%

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 35.0 Visit(s) per Year

YES

$45.00

100.00%
Rehabilitative Speech Therapy

Limit: 35.0 Visit(s) per Year

YES

$45.00

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

YES

$85.00

100.00%
Routine Foot Care

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.

NO
Skilled Nursing Facility

Limit: 25.0 Days per Year

YES

$2000.00 Copay per Stay

100.00%
Specialist Visit
YES

$85.00

100.00%
Specialty Drugs

If copay applies, copay amount is for 30 day supply.

YES

$500.00

100.00%
Substance Abuse Disorder Inpatient Services

Certain services require preauthorization.

YES

$2000.00 Copay per Stay

100.00%
Substance Abuse Disorder Outpatient Services

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.

YES

$45.00

100.00%
Transplant

Preauthorization is required.

YES

20.00%

100.00%
Transplant Donor Coverage
YES

20.00%

100.00%
Treatment for Temporomandibular Joint Disorders

Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed.

YES

20.00%

100.00%
Urgent Care Centers or Facilities
YES

$85.00

$85.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging

Refer to Plan Document for cost associated with certain outpatient laboratory and professional services.

YES

$125.00

100.00%

BSW Prime Silver HMO 005 ($0 deductible, one free PCP visit, $0 Pediatric PCP visit) Health Insurance Plan Variant 40788TX0460005-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.71913887
Begin Primary Care Cost-Sharing After Number Of Visits 1
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Silver Off Exchange Plan
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, Pregnancy
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID TXF001
Formulary URL URL
HIOS Product ID 40788TX046
Import Date 1/25/2023 1:00
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 40788
Issuer Marketplace Marketing Name Baylor Scott and White Health Plan
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Silver
Multiple In Network Tiers No
National Network No
Network ID TXN001
Out of Country Coverage No
Out of Service Area Coverage No
Out of Service Area Coverage Description Emergency Only
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan ID (Standard Component ID with Variant) 40788TX0460005-00
Plan Marketing Name BSW Prime Silver HMO 005 ($0 deductible, one free PCP visit, $0 Pediatric PCP visit)
Plan Type HMO
Plan Variant Marketing Name BSW Prime Silver HMO 005 ($0 deductible, one free PCP visit, $0 Pediatric PCP visit)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $5,000
SBC Scenario, Having a Baby, Deductible $0
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $90
SBC Scenario, Having Diabetes, Copayment $900
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $40
SBC Scenario, Treatment of a Simple Fracture, Copayment $1,700
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID TXS001
Source Name HIOS
Plan ID 40788TX0460005
State Code TX
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 20.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $0
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Individual Not Applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $18200 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9100 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,100
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual Not Applicable
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of BSW Prime Silver HMO 005 ($0 deductible, one free PCP visit, $0 Pediatric PCP visit) Health Insurance Plan, 40788TX0460005

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about BSW Prime Silver HMO 005 ($0 deductible, one free PCP visit, $0 Pediatric PCP visit), 40788TX0460005 Health Insurance Plan, 40788TX0460005

  • Does BSW Prime Silver HMO 005 ($0 deductible, one free PCP visit, $0 Pediatric PCP visit) Health Insurance Plan, 40788TX0460005 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (40788TX0460005) Health Insurance Plan, Variant (40788TX0460005-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy

    Does (40788TX0460005) Health Insurance Plan, Variant (40788TX0460005-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (40788TX0460005) Health Insurance Plan, Variant (40788TX0460005-00) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan). Details: Emergency Only

    Does (40788TX0460005) Health Insurance Plan, Variant (40788TX0460005-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy

    Does BSW Prime Silver HMO 005 ($0 deductible, one free PCP visit, $0 Pediatric PCP visit) Health Insurance Plan, Variant (40788TX0460005-00) offer Disease Management Programs for Asthma?

    Yes, the BSW Prime Silver HMO 005 ($0 deductible, one free PCP visit, $0 Pediatric PCP visit) Health Insurance Plan Variant 40788TX0460005-00 offers Disease Management Program for Asthma.

    Does BSW Prime Silver HMO 005 ($0 deductible, one free PCP visit, $0 Pediatric PCP visit) Health Insurance Plan, Variant (40788TX0460005-00) offer Disease Management Programs for Heart disease?

    Yes, the BSW Prime Silver HMO 005 ($0 deductible, one free PCP visit, $0 Pediatric PCP visit) Health Insurance Plan Variant 40788TX0460005-00 offers Disease Management Program for Heart disease.

    Does BSW Prime Silver HMO 005 ($0 deductible, one free PCP visit, $0 Pediatric PCP visit) Health Insurance Plan, Variant (40788TX0460005-00) offer Disease Management Programs for Diabetes?

    Yes, the BSW Prime Silver HMO 005 ($0 deductible, one free PCP visit, $0 Pediatric PCP visit) Health Insurance Plan Variant 40788TX0460005-00 offers Disease Management Program for Diabetes.

    Does BSW Prime Silver HMO 005 ($0 deductible, one free PCP visit, $0 Pediatric PCP visit) Health Insurance Plan, Variant (40788TX0460005-00) offer Disease Management Programs for Pregnancy?

    Yes, the BSW Prime Silver HMO 005 ($0 deductible, one free PCP visit, $0 Pediatric PCP visit) Health Insurance Plan Variant 40788TX0460005-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API