Coverage under this plan qualifies as minimum essential coverage.  Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

Our health coverage meets the minimum value standard of 60% established by the ACA. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits. The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure.

See www.opm.gov/healthcare-insurance for enrollment information as well as:

• Information on the FEHB Program and plans available to you
• A health plan comparison tool
• A list of agencies that participate in Employee Express
• A link to Employee Express
• Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, give you other plans' brochures and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

• When you may change your enrollment;
• How you can cover your family members;
• What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire;
• When your enrollment ends; and
• When the next Open Season for enrollment begins.

We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office. For information on your premium deductions, you must also contact your employing or retirement office.

Once enrolled in your FEHB Program Plus, you should contact your carrier directly for address updates and questions about your benefit coverage.

Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee and one eligible member. Self and Family coverage is for the enrollee, and one or more eligible family members.  Family members include your spouse, and your dependent children under 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event.  The Self Plus One or Self and Family enrollment begin on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form.  Benefits will not be available to your spouse until you are married.  A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

Contact your employing or retirement office if you want to change from Self to Self Plus One or Self and Family. If you have a Self and Family enrollment, you may contact us to add a family member. 

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits. Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26. We will send written notice to you 60 days before we proactively disenroll your child on midnight of their 26th birthday unless your child is eligible for continued coverage because they are incapable of self-support due to a physical or mental disability that began before age 26.

If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child -outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage. For a complete list of QLEs, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events. If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

Family members covered under your Self and Family enrollment are your spouse (including your spouse by a valid common law marriage from a state that recognizes common-law marriages) and children as described below.  A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described below.

Family members covered under your Self and Family enrollment are your spouse (including your spouse by valid common-law marriage if you reside in a state that recognizes common-law marriages) and children as described in the chart below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described in the chart below.

Natural children, adopted children, and stepchildren
Coverage: Natural children, adopted children, and stepchildren are covered until their 26th birthday.

Foster children
Coverage: Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information.

Children incapable of self-support
Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information.

Married children
Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday.

Children with or eligible for employer-provided health insurance
Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday.

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother's maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

OPM has implements the Federal Employees Health Benefits Children’s Equity Act of 2000. This law mandates that you be enrolled for Self and Family coverage in the FEHB Program if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows:

• If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self and Family coverage, as appropriate in the lowest-cost nationwide plan option as determined by OPM.
• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self and Family in the same option of the same plan; or
• If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate in the lowest-cost nationwide plan option as determined by OPM.

As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children.

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect. Contact your employing office for further information.

The benefits of this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2024 benefits of your prior plan or option.  If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option.  However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2023 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage (i.e., you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed for services received directly from your provider. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage.

When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).

You will receive an additional 31 days of coverage, for no additional premium, when:

• Your enrollment ends, unless you cancel your enrollment, or
• You are a family member no longer eligible for coverage.

Any person covered under the 31 day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60th day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC).

If you are an enrollee and your divorce or annulment is final, your ex-spouse cannot remain covered as a family member under your Self Plus One or Self and Family enrollment. You must contact us to let us know the date of the divorce or annulment and have us remove your ex-spouse. We may ask for a copy of the divorce decree as proof.  In order to change enrollment type, you must contact your employing or retirement office. A change will not automatically be made.

If you were married to an enrollee and your divorce or annulment is final, you may not  remain covered as a family member under your former spouse’s enrollment.  This is the case even when the court has ordered your former spouse to provide health coverage for you.  However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC).  If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get information about your coverage choices.  You can also visit OPM’s website at https://www.opm.gov/healthcare-insurance/life-events/memy-family/im-separated-or-im-getting-divorced/#url=Health. We may request that you verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, or if you are a covered child and you turn 26, 

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or retirement office or from www.opm.gov/healthcare-insurance. It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a tax credit that lowers your monthly premiums. Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll. Finally, if you qualify for coverage under another group health plan (such as your spouse’s plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHB Program coverage.

You may convert to a non-FEHB individual policy if:

• Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert);
• You decided not to receive coverage under TCC or the spouse equity law, or
• You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal or Tribal service, your employing office will notify you of your right to convert.  You must contact us in writing within 31 days after you receive this notice.  However, if you are a family member who is losing coverage, the employing or retirement office will not notify you.  You must contact us in writing within 31 days after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions.  When you contact us we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act's Health Insurance Marketplace in your state.  For assistance in finding coverage, please contact us at 844-633-5325 or visit our website at bswhealthplan.com/fehb.

If you would like to purchase health insurance through the ACA's Health Insurance Marketplace, please visit www.HealthCare.gov. This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 844-633-5325 or write to us at:

Baylor Scott & White Health Plan
1206 West Campus Drive
Temple, TX 76502

You may also request replacement cards through our website: https://bswhealthplan.com/fehb.

You get care from "Plan providers" and "Plan facilities." You will only pay copayments and/or coinsurance. We are an Open Access health plan, so you can receive covered services from a participating provider without a referral from a primary care provider or by another participating provider in the network.

 FEHB Carriers must have clauses in their in-network (participating) providers agreements.  These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount.  If an in-network provider bills you for covered services over your normal cost share (deductible, copay, co-insurance) contact your Carrier to enforce the terms of its provider contract.

Plan providers are physicians and other healthcare professionals in our service area that we contract with to provide covered services to our members.  Services by Plan Providers are covered when acting within the scope of their license or certification under applicable state law. We credential Plan providers according to national standards. 

Benefits are provided under this Plan for the services of covered providers, in accordance with Section 2706(a) of the Public Health Service Act. Coverage of practitioners is not determined by your state’s designation as a medically underserved area. 

We list covered providers in the provider directory, which we update monthly on our website, https://bswhealthplan.com/fehb.  Both the Standard Plan option and the Basic plan option utilize the BSW Premier HMO network.

This plan recognizes that transgender, non-binary, and other gender diverse members require health care delivered by healthcare providers experienced in gender affirming health. Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex or gender.

This plan provides Care Coordinators for complex conditions and can be reached by calling 844-279-7589 for assistance.

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members.  We list these in the provider directory, which we update monthly on our website, https://bswhealthplan.com/fehb.

Both the Standard Plan option and the Basic Plan option utilize the BSW Premier HMO network.

Now that you have chosen Baylor Scott & White Health Plan (BSWHP), your next choice will be deciding who will provide most of your health care services. BSWHP is an Open Access Health Plan. A member can go to any network provider without a referral.

Members may choose a network primary care provider (PCP) if they would like, but PCP designation is not required by BSWHP. If you choose a PCP, you may choose from the following:

• Family Medicine doctors treat all age groups from newborn to the elderly
• Internal Medicine doctors treat patients 18 age or older
• Pediatric doctors treat children up to age 18

In selecting a PCP, consider which clinic or doctor would be most convenient to meet your own medical needs. You and your dependents may select his or her own PCP.  You can change your PCP at any time you choose.

All non-emergent medical care must be provided by BSW Premier HMO network providers. BSWHP does not require a referral from a primary care provider before you can access a specialist. Simply call the specialist’s office and make an appointment.

Please note: Due to the nature of some specialties, some provider offices may require a referral prior to making your appointment. This is the choice of that physician’s office and not a requirement of BSWHP.

Behavioral Health Services as well as certain other services may require prior authorization through BSWHP Health Services. Examples of services, procedures, or tests that may require prior notification and/or authorization by BSWHP are listed on page 16.

Here are some other things you should know about specialty care:

• If your current specialist does not participate with us, you must receive treatment from a specialist who does.  Generally, we will not pay for you to see a specialist who does not participate with our Plan.
• If you are seeing a specialist and your specialist leaves the Plan, call Health Services and they will arrange for you to see another specialist.  You may receive services from your current specialist until we can make arrangements for you to see someone else.
• If you have a chronic and disabling condition and lose access to your specialist because we:
  • terminate our contract with your specialist for other than cause;
  • drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program plan; or
  • reduce our service area and you enroll in another FEHB plan;

You may be able to continue seeing your specialist for up to 90 days after you receive notice of the change.  Contact us, or if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

For elective hospital admissions and certain types of procedures, you need a prior authorization from the BSWHP Health Services before the day of the procedure, if you want to be sure BSWHP will pay for the hospital and procedure. Each day you are in the hospital, BSWHP nurses and Medical Directors review with your physician the level of care you require and work with him/her to determine the amount of time you need to stay in the hospital.

If you are hospitalized as a result of an emergency, you should contact the BSWHP Health Services within 24 – 48 hours of any admission at 844-633-5325. Coverage for continued treatment is assured when approval is obtained from BSWHP Health Services. BSWHP will approve or deny the requested post-stabilization treatment within one hour if contacted by the provider or facility. Emergency care in a hospital emergency room requires a copayment, which will be waived if hospital admission occurs within 24 hours.

We pay for covered services from the effective date of your enrollment.  However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 844-633-5325.  If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

• you are discharged, not merely moved to an alternative care center;
• the day your benefits from your former plan run out; or
• the 92nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person.  If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply.  In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.

For elective hospital admissions and certain types of procedures listed under "Other Services," you need a prior authorization from the BSWHP Health Services before the day of the procedure.  If you want to be sure BSWHP will pay for the hospital and procedure, you must get prior approval for certain services.  Failure to do so could result in denial of benefits.

For certain services, your provider must obtain prior approval from us.  Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.

Notification requested:  

1. Acute (contracted ) hospital admissions (medical, surgical, behavioral health)
2. Admissions to inpatient or outpatient (contracted) hospice programs

Prior Authorization required:

All services requested to be provided by non-contracted providers must have prior authorization.

1. Admissions to LTAC, Rehabilitation, and SNF facilities
2. Admissions to behavioral health/substance abuse residential, partial hospitalization, and day programs (not office visits to contracted providers)
3. Neuropsychological and psychological testing
4. Applied behavioral analysis therapy
5. Outpatient electroconvulsive therapy (ECT)
6. Solid organ and stem cell transplants (Pre-Transplant Eval; Transplant; Post-Transplant Care)
7. Weight loss (bariatric) surgeries (if a covered benefit, not covered by many plans)
8. Procedures which may be considered cosmetic and thus not covered (e.g. facelift, brow lift, blepharoplasty, liposuction, abdominoplasty, breast reconstruction (not associated with medically indicated mastectomy), surgery for gynecomastia, rhinoplasty, genioplasty, treatment of varicose veins, etc.)
9. Orthognathic surgery
10. Treatments for sleep apnea (other than CPAP/CPAP-related supplies)
11. Home health services, including all requests for hourly or private duty nursing
12. Durable medical equipment (DME) – See Addendum A for specific items
13. Orthotics and prosthetics – See Addendum B for specific items
14. Spinal fusion and vertebroplasty
15. X-Stop Spacer for Spinal Stenosis
16. Artificial Disc Implantation/Replacement
17. Ventricular assist devices (VAD)
18. Genetic testing (Except chromosome testing)
19. Intrathecal Pain Pump Implantation/Therapy
20. Spinal Stimulators
21. Vagal Nerve Stimulators
22. Fixed Wing or Jet Medical Transports
23. IVIG Therapy
24. Lung Volume Reduction Surgery
25. Transaortic or Transapical Valve Insertion or Replacement (TAVI/TAVR)
26. Insulin Pumps and/or Continuous Glucose Monitors
27. Bone-Anchored Hearing Aids (BAHA)
28. Cochlear Implants
29. Dental Services and Anesthesia for Dental Services
30. Epidural Adhesiolysis

Addendum A - Durable Medical Equipment (purchase or rental):

• Oral appliances
• Electric, semi-electric, air fluidized, and advanced technology beds and related equipment
• Oxygen and related equipment
• Ventilators and related equipment
• High frequency chest wall oscillation air-pulse generator system; including vest, hose, and related equipment
• Bone stimulators
• Spinal Cord Stimulators
• Functional neuromuscular stimulation, transcutaneous stimulation of sequential muscle groups of ambulation with computer control, the entire system
• Functional electrical stimulation, transcutaneous stimulation of nerve and/or muscle groups, complete system
• Power wheelchairs and related equipment
• Power operated vehicles and related equipment
• Custom made and specially sized wheelchairs and related equipment
• Dialysis equipment
• Defibrillators and related equipment (includes chest/vest defibrillators)
• Non-specific, miscellaneous, and unlisted DME codes

Addendum B – Orthotics and Prosthetics

• Breast implants (unless status post medically indicated mastectomy)
• Lower and upper limb prosthetics (including myoelectric and microprocessor controlled) and related equipment/supplies
• Facial, nasal, and auricular prostheses
• Non-specific, miscellaneous, and unlisted orthotic and prosthetic codes

First, your physician, your hospital, you, or your representative, must call us at 888-316-7947 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

• enrollee’s name and Plan identification number;
• patient’s name, birth date, identification number and phone number;
• reason for hospitalization, proposed treatment, or surgery;
• name and phone number of admitting physician;
• name of hospital or facility; and
• number of days requested for hospital stay.

For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization.  We will make our decision within 15 days of receipt of the pre-service claim.  If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period.  Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours.  If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to provide notice of the specific information we need to complete our review of the claim.  We will allow you up to 48 hours from the receipt of this notice to provide the necessary information.  We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) to end of the time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM.  Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision or by calling us at 888-316-7947.  You may also call OPM’s Health Insurance 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, call us at 888-316-7947. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

A concurrent care claim involves care provided over a period of time or over a number of treatments.  We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends.  If we believe a reduction or termination is warranted we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect. 

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim we will make a decision within 24 hours after we receive the claim.

If you are hospitalized as a result of an emergency, you should contact the BSWHP Health Services within 24 – 48 hours of any admission at 888-316-7947. Coverage for continued treatment is assured when approval is obtained from the BSWHP Medical Director through BSWHP Health Services. BSWHP will approve or deny the requested post-stabilization treatment within one hour if contacted by the provider or facility. Emergency care in a hospital emergency room requires a copayment, which will be waived if hospital admission occurs within 24 hours.

You do not need precertification of a maternity admission for a routine delivery.  However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days.  Further, if your baby stays after you are discharged, your physician or the hospital must contact us for precertification of additional days for your baby.

Note: When a newborn requires definitive treatment during or after the mother’s hospital stay, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim we will make a decision within 24 hours after we receive the claim.

Without preauthorization, BSWHP does not pay for out-of-network elective procedures, or treatment for minor illness. BSWHP will not assume financial responsibility for out-of-network treatment if you are well enough to return to a BSWHP provider or facility.

BSWHP out-of-network benefits are limited to accidental injuries and sudden illnesses.

When seeking treatment in an out-of-network emergency room, provide your member identification card. This will speed up the processing and payment of your bill by BSWHP. This will also allow the treating physician to discuss your emergency care with your provider if necessary.

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below.  If your claim is in reference to a contraceptive, call 844-633-5325.

If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8.

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision.  Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to:

1. Precertify your hospital stay or, if applicable, arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply; or
2. Ask you or your provider for more information.
   
   You or your provider must send the information so that we receive it within 60 days, of our request.  We will then decide within 30 more days.
   
   If we do not receive the information within 60 days we will decide within 30 days of the date the information was due.  We will base our decision on the information we already have.  We will write to you with our decision.
3. Write to you and maintain our denial.

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision.  Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request.  We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods.

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc. when you receive certain services.

Example: When you see your primary care physician, you pay a copayment of $25 per office visit, and when you go into an Urgent Care center, you pay $50 per visit.

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count toward any deductible.

A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for them. Copayments and coinsurance amounts do not count toward your deductible.  When a covered service or supply is subject to a deductible, only the Plan allowance for the service or supply that you then pay counts toward meeting your deductible.

Under Standard Option, the calendar year deductible is $300 per person.  After the deductible amount is satisfied for an individual, covered services are payable for that individual.  Under Self Plus One enrollment, both family members must meet the individual deductible. Under Self and Family enrollment, an individual may meet the individual deductible, or all family members' individual deductibles are considered to be satisfied when the family members' deductibles are combined and reach $600.

Under Basic Option, the calendar year deductible is $1,500 per person.  After the deductible amount is satisfied for an individual, covered services are payable for that individual.  Under Self Plus One enrollment, both family members must meet the individual deductible. Under Self and Family enrollment, an individual may meet the individual deductible, or all family members' individual deductibles are considered to be satisfied when the family members' deductibles are combined and reach $3,000.

If you change plans during Open Season, you do not have to start a new deductible under your prior plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.

If you change options in this Plan during the year, we will credit the number of covered expenses already applied toward the deductible of your old option to the deductible of your new option.

Coinsurance is the percentage of our allowance that you must pay for your care. 

Our "Plan allowance" is the amount we use to calculate our payment for certain types of covered services.  See definition of Plan allowance in Section 10.

You should also see section Important Notice About Surprise Billing - Know Your Rights below that describes your protections against surprise billing under the No Surprises Act.

Under Standard and Basic Options, we limit your annual out-of-pocket expenses for the covered services you receive to protect you from unexpected healthcare costs. When your eligible out-of-pocket expenses reach this catastrophic protection maximum, you no longer have to pay the associated cost-sharing amounts for the rest of the calendar year.  For Self Plus One and Self and Family enrollments, once any individual family member reaches the Self Only catastrophic protection out-of-pocket maximum during the calendar year, that member's claims will no longer be subject to associated cost-sharing amounts for the rest of the year. All other family members will be required to meet the balance of the catastrophic protection out-of-pocket maximum.

Note: Certain types of expenses do not accumulate to the maximum.

Standard Option - For Self Only enrollment, your out-of-pocket maximum for the deductible, and for eligible coinsurance and copayment amounts, is $5,500 for Self Only, $11,000 for Self Plus One, or $11,000 for Self and Family.

Basic Option - For Self Only enrollment, your out-of-pocket maximum for the deductible, and for eligible coinsurance and copayment amounts, is $6,000 for Self Only, $12,000 for Self Plus One, or $12,000 for Self and Family.

Be sure to keep accurate records of your copayments since you are responsible for informing us when you reach the maximum.

If you change options in this Plan during the year, we will credit the number of covered expenses already accumulated toward the catastrophic out-of-pocket limit for your old option to the catastrophic protection limit of your new option.

If you changed to this Plan during Open Season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan’s catastrophic protection benefit during the prior year will be covered by your prior plan if they are for care you received in January before your effective date of coverage in this Plan.  If you have already met your prior plan’s catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan.  If you have not met this expense level in full, your prior plan will first apply your covered out-of-pocket expenses until the prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan.  Your prior plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

The No Surprises Act (NSA) is a federal law that provides you with protections against "surprise billing" and "balance billing" for out-of-network emergency services; out-of-network non-emergency services provided with respect to a visit to a participating health care facility; and out-of-network air ambulance services.

A surprise bill is an unexpected bill you receive for:

• emergency care – when you have little or no say in the facility or provider from whom you receive care, or for
• non-emergency services furnished by nonparticipating providers with respect to patient visits to participating health care facilities, or for
• air ambulance services furnished by nonparticipating providers of air ambulance services.

Balance billing happens when you receive a bill from the nonparticipating provider, facility, or air ambulance service for the difference between the nonparticipating provider's charge and the amount payable by your health plan.

Your health plan must comply with the NSA protections that hold you harmless from surprise bills.

In addition, your health plan adopts and complies with the surprise billing laws of Texas.

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to bswhealthplan.com/fehb or contact the health plan at 844-633-5325.

• Healthcare FSA (HCFSA) - Reimburses you for eligible out-of-pocket healthcare expense (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you, your tax dependents, and your adult children (through the end of the calendar year in which they turn 26).
• FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans.  This means when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan. 

Outpatient professional services of physicians and other healthcare professionals

• Physician’s office
• Office medical consultations
• Second Surgical opinions
• Home visits
• Advance care planning
• Blood Pressure Monitor Training

Primary Care Provider (PCP) Office Visit

• $25 Copay
• $0 Copay for first adult non-preventive visit
• $0 Copay for dependents ages 0 - 18

Specialist Office Visit

• $50 Copay

Primary Care Provider (PCP) Office Visit

• $25 Copay
• $0 Copay for first adult non-preventive visit
• $0 Copay for dependents ages 0 - 18

Specialist Office Visit

• $50 Copay

Professional services of physicians

• In an urgent care center
• During a hospital stay  
• In a skilled nursing facility

$50 per visit to an urgent care center

10% for inpatient hospital stay (deductible applies)

$75 per visit to an urgent care center

20% for inpatient hospital stay (deductible applies)

Conditions treated through E-Visits include:

• acne
• canker or cold sore
• cold
• sinus infection or sore throat
• constipation and/or diarrhea (irritable bowel syndrome)
• female bladder infection (UTI)
• hay fever/allergies
• influenza (the flu)
• influenza prevention
• pink eye (conjunctivitis)
• vaginal yeast infection
• quitting tobacco

Visit the E-Vist site, Https://evisit.baylorscottandwhite.com/ or mybswhealth.com.

$25 per E-Visit

$25 per E-Visit

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine Pap tests
• Pathology
• X-rays
• Non-routine mammograms
• Ultrasound
• Electrocardiogram and EEG
• BRCA testing - Per the PPACA, the Plan will cover BRCA testing for women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2. 

Nothing

• CT/Cat Scan
• MRI
• Angiograms
• Myelography
• PET Scans
• Stress Tests 

10% coinsurance ( deductible applies)

20% per procedure (deductible applies)

Routine physical every 12 months

The following preventive services are covered at the time interval recommended at each of the links below.

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/Tdap, and human papillomavirus (HPV).  For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.uspreventiveservicestaskforce.org/uspstf/recommendations-topics/uspstf-a-and-b-recommendations
• Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening.  For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• Individual counseling on prevention and reducing health risks
• Preventive care benefits for women such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence.  For a complete list of preventive care benefits for women go the the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder

Nothing

• Routine mammogram – covered for women 

Nothing

• Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service is done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

• Medical Nutrition Therapy and Intensive Behavioral Therapy for the prevention of obesity related comorbidities.

Nothing

Not covered:

• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.

• Immunizations, boosters, and medications for travel or work-related exposure.

All charges

All charges

• Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics.  For a complete list of the American Academy of Pediatrics Bright Future Guidelines go to https://brightfutures.aap.org
• Immunizations such as DTaP/Tdap. Polio. Measles, Mumps and Rubella (MMR), and Varicella.  For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html
• You may also find a complete list of preventive case services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Nothing

Complete maternity (obstetrical) care, such as:

• Prenatal and Postpartum care
• Screening for gestational diabetes 
• Delivery
• Screening and counseling for prenatal and postpartum depression

Nothing for prenatal care, first postpartum care visit, screening for gestational diabetes for pregnant women between 24 and 28 weeks gestation or first prenatal visit for women at a high risk or inpatient professional delivery services.

$50 per office visit for all postpartum care visits thereafter. 

Nothing for prenatal care, first postpartum care visit, screening for gestational diabetes for pregnant women between 24 and 28 weeks gestation or first prenatal visit for women at a high risk or inpatient professional delivery services.

$50 per office visit for all postpartum care visits thereafter. 

Breastfeeding support, supplies, and counseling for each birth.

Note: Breastfeeding supplies (see DME, Page (Applies to printed brochure only))

Note: Here are some things to keep in mind:

• You do not need to precertify your vaginal delivery; see Section 3 for other circumstances, such as extended stays for you or your baby.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will cover an extended stay (you do not need to precertify the normal length of stay). We will extend your inpatient stay for you or your baby if medically necessary, but you, your representative, your doctor, or your hospital must precertify the extended stay. See Section 3 for other circumstances.
• We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment if we cover the infant under a Self Plus One and Family enrollment.  Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and Surgery benefits (Section 5b).
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

Note: When a newborn requires definitive treatment during or after the mother’s confinement, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

Nothing

Nothing

Contraceptive counseling on an annual basis

Nothing

Nothing

A range of voluntary family planning services limited to:

• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo Provera)
• Intrauterine devices (IUDs)
• Diaphragms
• Tubal ligation

Note: We cover oral contraceptives under the prescription drug benefit.

Nothing

Nothing

Voluntary Sterilization (See Surgical Procedures Section 5 (b)

$25 Copay for PCP office visit

$50 Copay for Specialist office visit

$25 Copay for PCP office visit

$50 Copay for Specialist office visit

Plan exclusions:

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling

All charges

All charges

Definition of Infertility: The inability to carry a pregnancy to live birth without the use of birth control after unprotected sexual intercourse / failure of egg and sperm contact and uterine implantation without medical assistance after 12 months if under age 35, or 6 months if age 35 years or older. Infertility may also be justified based on the individual having a medical or other recognized condition as a cause of infertility.  

Diagnosis and treatment of infertility specific to:

• Artificial insemination (up to 6 cycles annually):
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)
• In Vitro Fertilization (up to 3 cycles annually)
• Iatrogenic fertility preservation procedures (retrieval of and freezing
  of eggs or sperm) for members facing the possibility of
  infertility caused by chemotherapy, pelvic radiotherapy,
  other gonadotoxic therapies, or ovary or testicle removal
  for treatment of disease, or associated with medical and
  surgical gender transition treatment. Subject to medical
  necessity. Requires prior authorization.
  If a member terms
  from the plan benefits for storage are no longer applicable.
• Fertility Drugs (see Section 5f)

There is no coverage for infertility for any other unlisted service including reversal of previous sterilization procedures.

30% of charges after deductible. Annual maximum benefit of $15,000 for IVF infertility services. 

50% of charges after deductible. Annual maximum benefit of $15,000 for IVF infertility services.

Plan exclusions:

 - Infertility services after voluntary sterilization 

 - Fertility drugs for procedures excluded under this contract

 - Assisted reproductive technology (ART) procedures, such as:

• Embryo transfer and gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
• Services and supplies related to ART procedures

 - Cost of donor sperm

 -  Cost of donor egg

All charges

All charges

• Testing and treatment
• Allergy injections
• Allergy serum

 (deductible applies)

20% coinsurance (deductible applies)

Plan exclusions:

• Provocative food testing
• Sublingual allergy desensitization
• All other treatment not specifically listed as covered

All charges

• Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 38.

• Respiratory and inhalation therapy
• Cardiac rehabilitation following qualifying event/condition is provided for up to 60 sessions
• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy
• Applied Behavior Analysis (ABA) - Children with autism spectrum disorder
• Growth hormone therapy (GHT)

$50 per visit to a specialist

$50 per visit to a specialist

Up to 60 visits (combines physical, occupational and/or speech therapy) per condition per benefit period for the services of the following qualified providers.

• Physical therapists
• Occupational therapist
• Speech therapist

Note: We only cover therapy when a physician

• Orders the care
• Identifies the specific professional skills the patient requires and the medical necessity for skilled services; and
• Indicates the length of time the services are needed.

$50 per visit to a specialist

Nothing per visit during a covered inpatient admission

$50 per visit to a specialist

Nothing per visit during a covered inpatient admission

Plan exclusions:

• Long-term rehabilitative therapy
• Exercise programs

All charges

All charges

$50 per visit to a specialist

$50 per visit to a specialist

• For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by a primary care, specialist or audiologist

Note: For routine hearing screening performed during a child’s preventive care visit, see Section 5(a) Preventive care, children.

$25 per visit to PCP

$50 per visit to specialist

$25 per visit to PCP

$50 per visit to specialist

• Annual eye refraction (determining lens prescription)

Note: See Preventive care, children, for eye exams for children

$50 per visit to a specialist

$50 per visit to a specialist

Plan exclusions:

• Eyeglasses or contact lenses and examinations for them, except as shown above
• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery

All charges

All charges

Routine foot care

• Active treatment for a metabolic, peripheral vascular disease and systemic conditions, such as diabetes.

Note: See Orthopedic and prosthetic devices for information on podiatric shoe inserts.

$25 per visit to PCP

$50 per visit to specialist

$25 per visit to PCP

$50 per visit to specialist

Plan exclusions:

• Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
• Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

All charges

All charges

Note: All orthotics and prosthetics must be pre-authorized.

• Lower and upper limb prosthetics (including myoelectric and microprocessor controlled) and related equipment/supplies
• Facial, nasal, and auricular prostheses
• Non-specific, miscellaneous, and unlisted orthotic and prosthetic codes
• Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy.

For information on the professional charges for the surgery to insert an implant, see Section 5(b) Surgical procedures. For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c) Services provided by a hospital or other facility, and ambulance services.

30% coinsurance (deductible applies)

30% coinsurance (deductible applies)

Plan exclusions:

• Orthopedic and corrective shoes
• Arch supports
• Foot orthotics
• Heel pads and heel cups
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices

Prosthetic repairs, maintenance, and cleaning due to abnormal wear and tear or abuse.

Prosthetic replacements are subject to preauthorization but do not require a waiting period.

All charges

All charges

Note: All DME must be pre-authorized for coverage.

We cover the rental or purchase of durable medical equipment, at our option, including repair and adjustment. Covered items include:

• Oral appliances
• Electric, semi-electric, air fluidized, and advanced technology beds and related equipment
• Oxygen and related equipment
• Ventilators and related equipment
• High frequency chest wall oscillation air-pulse generator system; including vest, hose, and related equipment
• Bone stimulators
• Spinal Cord Stimulators
• Functional neuromuscular stimulation, transcutaneous stimulation of sequential muscle groups of ambulation with computer control, the entire system
• Functional electrical stimulation, transcutaneous stimulation of nerve and/or muscle groups, complete system
• Power wheelchairs and related equipment
• Power operated vehicles and related equipment
• Custom made and specially sized wheelchairs and related equipment
• Dialysis equipment
• Defibrillators and related equipment (includes chest/vest defibrillators)
• Breast Pump Rentals
• Insulin pumps
• Blood pressure monitors
• Continuous glucose monitors
• Non-specific, miscellaneous, and unlisted DME codes

Call us at 844-633-5325 as soon as your Plan physician prescribes this equipment. We will arrange with a healthcare provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

30% coinsurance (deductible applies)

30% coinsurance (deductible applies)

Plan exclusions:
Shoe inserts and other removable devices (see 'Plan exclusions' list under Orthopedic and prosthetic devices).

All charges

• Home healthcare ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide.
• Services include oxygen therapy, intravenous therapy and medications.

$50 per visit

$50 per visit

Plan exclusions:

• Nursing care requested by, or for the convenience of, the patient or the patient’s family;
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative

All charges

All charges

• Manipulation of the spine and extremities

Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack applications.

35 visit limit per year

$50 per visit 

$50 per visit

"No benefit"

All charges

All charges

Coverage is provided for:

Tobacco Cessation programs, including individual/group/phone counseling, over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence (if prescribed by a physician and purchased at a network pharmacy).

• Diabetes self-management
• Multicomponent family centered programs focused on childhood obesity that are part of intensive behavioral interventions (behavioral change counseling for health diet and physical activity)

No cost for tobacco cessation programs.

$25 per visit to PCP

$50 per visit to specialist

No cost for tobacco cessation programs.

$25 per visit to PCP

$50 per visit to specialist

Wellness Programs

• Online Lifestyle Management Programs

No cost for participating in wellness programs.

No cost for participating in wellness programs.

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre-and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Surgical treatment of severe obesity (bariatric surgery)
• Insertion of internal prosthetic devices. See 5(a) –Orthopedic and prosthetic devices for device coverage information
• Voluntary sterilization (e.g., tubal ligation, vasectomy)
• Treatment of burns

10% coinsurance (deductible applies)

20% coinsurance (deductible applies)

Plan exclusions:

• Reversal of voluntary sterilization-
• Routine treatment of conditions of the foot - (see Foot care)

All charges

All charges

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • the condition produced a major effect on the member’s appearance and
  • the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are protruding ear deformities; cleft lip; cleft palate; birthmarks; and webbed fingers and toes.
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • Surgery to produce a symmetrical appearance of breasts;
  • Treatment of any physical complications, such as lymphedemas;
  • Breast prostheses and surgical bras and replacements (see Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

10% coinsurance (deductible applies)

20% coinsurance (deductible applies)

Plan exclusions:

• Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury.

All charges

All charges

Gender Affirming Care Surgical treatment includes but may not be limited to the following, based on medical necessity and with prior authorization:

• Amputation of penis
• Clitoroplasty for intersex state
• Construction of artificial vagina
• Facial gender affirming care surgery
• Gonadectomy
• Hysterectomy
• Insertion of testicular prosthesis
• Intersex surgery female to male [a series of staged procedures]
• Intersex surgery male to female [a series of staged procedures]
• Mastectomy
• Orchiectomy
• Penile prothesis 
• Perineoplasty
• Plastic repair of introitus
• Salpingo-oophorectomy
• Scrotoplasty
• Urethroplasty (reconstruction of female urethra)
• Vaginectomy
• Vaginoplasty for intersex state
• Vulvectomy

10% Coinsurance

(deductible applies)

20% Coinsurance

(deductible applies)

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones;
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
• Removal of stones from salivary ducts;
• Excision of leukoplakia or malignancies;
• Excision of cysts and incision of abscesses when done as independent procedures; and
• Other surgical procedures that do not involve the teeth or their supporting structures.

10% coinsurance (deductible applies)

20% coinsurance (deductible applies)

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

All charges

All charges

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. See Other services in Section 3 for prior authorization procedures.

• Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
• Cornea
• Heart
• Heart-lung
• Intestinal transplants

             - Isolated Small intestine

             - Small intestine with the liver 

             - Small intestine with multiple organs such as the liver, stomach, and pancreas

• Kidney
• Kidney-Pancreas
• Liver 
• Lung: Single/bilateral/lobar
• Pancreas 

10% coinsurance (deductible applies)

20% coinsurance (deductible applies)

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Refer to Other services in Section 3 for prior authorization procedures.

• Autologous tandem transplants for
  • AL Amyloidosis
  • Multiple myelomas (de novo and treated)
  • Recurrent germ cell tumors (including testicular cancer)

10% coinsurance (deductible applies)

20% coinsurance (deductible applies)

These tandem Blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan.  Refer to Other services in Section 3 for prior authorization procedures.

The Plan extends coverage for the diagnoses as indicated below.

• Allogeneic transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced neuroblastoma
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  •   Acute myeloid leukemia
  •   Amyloidosis
  •   Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  •   Hematopoietic stem cell trasnplant
  •   Hemoglobinopathy
  •   Infantile malignant osteopetrosis
  •   Kostmann’s syndrome
  •   Leukocyte adhesion deficiencies
  •   Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturna Hemoglobinuria, Pure Red Cell Aplasia)
  •   Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  •   Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler’s syndrome, Sanfilippo syndrome, Maroteaux-Lamy syndrome variants)
  •   Myelodysplasia/Myelodysplastic Syndromes
  •   Paroxysmal Nocturnal Hemoglobinuria
  •   Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
  •   Severe combined immunodeficiency
  •   Severe or very severe aplastic anemia
  •   Sickle cell anemia
  •   X-linked lymphoproliferative syndrome
• Autologous transplants for
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Breast Cancer
  • Ependymoblastoma
  • Epithelial ovarian cancer
  • Ewing’s sarcoma
  • Medulloblastoma
  • Multiple myelomas
  • Pineoblastoma
  • Neuroblastoma
  • Testicular, Mediastinal, Retroperitoneal, and ovarian germ cell tumors

10% coinsurance (deductible applies)

20% coinsurance (after deductible)

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan.

Refer to Other services in Section 3 for prior authorization procedures:

• Allogeneic transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Acute myeloid leukemia
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Myelodysplasia/Myelodysplastic Syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
•  Autologous transplants for
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Neuroblastoma

10% coinsurance (deductible applies)

20% coinsurance (deductible applies)

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of health approved clinical trial or a Plan-designated center of excellence if approved by the Plan’s medical director in accordance with the Plan’s protocols.

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient’s condition) if it is not provided by the clinical trial. Section 9 has additional information on costs related to clinical trials. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

• Allogeneic transplants for:
  • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)

• Mini-transplants (non-myeloablative allogeneic, reduced intensity conditioning or RIC)
• Autologous Transplants for
  • Advanced Childhood kidney cancers
  • Advanced Ewing sarcoma
  • Childhood rhabdomyosarcoma
  • Epithelial Ovarian Cancer
  • Mantle Cell (Non-Hodgkin lymphoma)
  • National Transplant Program (NTP) -

Note: When we cover related medical and hospital expenses of the donor when we cover the recipient. We cover donor testing for the actual solid organ donor or up to four bone marrow/stem cell transplant donors in addition to the testing of family members.

10% coinsurance (deductible applies)

20% coinsurance (deductible applies)

Plan exclusions:

• Donor screening tests and donor search expenses, except as shown above
• Implants of artificial organs
• Transplants not listed as covered

All charges

All charges

Professional services provided in –

• Hospital (inpatient)
• Hospital outpatient department
• Skilled nursing facility
• Ambulatory surgical center
• Office

10% coinsurance (deductible applies)

20% coinsurance (deductible applies)

Room and board, such as

• Ward, semiprivate, or intensive care accommodations
• General nursing care
• Meals and special diets

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

10% coinsurance  (deductible applies)

20% coinsurance (deductible applies)

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Take-home items
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

10% coinsurance (deductible applies)

20% coinsurance (deductible applies)

Plan exclusions:

• Custodial care
• Non-covered facilities, such as nursing homes, schools
• Personal comfort items, such as phone, television, barber services, guest meals and beds
• Private nursing care

All charges

All charges

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests, X-rays, and pathology services
• Administration of blood, blood plasma, and other biologicals
• Blood and blood plasma, if not donated or replaced
• Pre-surgical testing
• Dressings, casts, and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service
• Vasectomies
• Laparoscopies

10% coinsurance (deductible applies)

20% coinsurance (deductible applies)

• Extended care benefit
• Skilled nursing facility (SNF)

10% coinsurance  (deductible applies)

60 visit limit per year

20% coinsurance (deductible applies)

25 visit limit per year

Plan exclusions: Custodial care

All charges

All charges

Hospice services consist of medically necessary Hospice care that is recommended by a designated Participating Physician, approved in advance by the Medical Director, and provided by a licensed Hospice agency with which Health Plan has arranged for you or your covered dependent's care and treatment.

Nothing

Plan exclusions: Independent nursing, homemaker services.

All charges

All charges

• Local professional ambulance service when medically appropriate

$125 per trip (deductible applies)

20% coinsurance (deductible applies)

• Emergency care at a doctor’s office
• Emergency care at an urgent care center
• Emergency care as an outpatient at a hospital, including doctors’ services

Note: We waive the ER copay if you are admitted to the hospital.

$25 PCP, $50 Specialist
$50 per visit to an Urgent Care Center
10% coinsurance per Emergency Room visit (deductible applies)

$25 PCP, $50 Specialist
$75 per visit to an Urgent Care Center
20% coinsurance per Emergency Room visit (deductible applies)

Plan exclusions: Elective care or non-emergency care

All charges

• Emergency care at a doctor’s office
• Emergency care at an urgent care center
• Emergency care as an outpatient at a hospital, including doctors’ services

Note: We waive the ER copay if you are admitted to the hospital.

All charges
$50 per visit to an Urgent Care Center
10% coinsurance per visit to an Emergency Room (deductible applies)

All charges
$75 per visit to an Urgent Care Center
20% coinsurance per visit to an Emergency Room (deductible applies)

Plan exclusions:

• Elective care or non-emergency care and follow-up care recommended by non-Plan providers that have not been approved by the Plan or provided by Plan providers
• Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
• Medical and hospital costs resulting from a Normal full-term delivery of a baby outside the service area

All charges

Professional ambulance service when medically appropriate

Note: See 5(c) for non-emergency service.

$125 per trip (deductible applies)

20% coinsurance (deductible applies)

Plan exclusions:

Health Plan will not cover air transportation if ground transportation is medically appropriate and more economical.

All charges

All charges

When part of a treatment plan we approve, we cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their licenses, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists.

$25 per visit

$25 per visit

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders. Services include:

• Diagnostic evaluation
• Crisis intervention and stabilization for acute episodes
• Medication evaluation and management (pharmacotherapy)
• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
• Treatment and counseling (including individual or group therapy visits)
• Diagnosis and treatment of substance use disorders, including detoxification, treatment, and counseling
• Professional charges for intensive outpatient treatment in a provider’s office or other professional setting
• Electroconvulsive therapy
• Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder treatment practitioner 
• Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility 
• Inpatient diagnostic tests provided and billed by a hospital or other covered facility

$25 per visit

$25 per visit

Inpatient services provided and billed by a hospital or other covered facility

• Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services

10% coinsurance (deductible applies)

20% coinsurance (deductible applies)

Outpatient services provided and billed by a hospital or other covered facility

• Services in approved treatment programs, such as partial hospitalization, half-way house, residential treatment, full-day hospitalization, or facility-based intensive outpatient treatment

10% coinsurance (deductible applies)

20% coinsurance (deductible applies)

If your provider requests out-of-network services, they must be preauthorized by the BSWHP Medical Director for you to receive any benefits. Emergency admissions must be reported within two business days following the day of admission even if you have been discharged. Otherwise, there will be no coverage. See Section 3 for details.

Retail Prescription Drugs – (30-day supply)

30-day supplies of medications listed on the formulary are covered at the applicable copays. The following medications and supplies must be prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order program:

• Drugs and medications that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered
• Insulin
• Diabetic supplies limited to:
  • Disposable needles, test strips, lancets, lancet devices, meters, and syringes for the administration of covered medications.
• Drugs for sexual dysfunction (covered at Non-Preferred copay)
• Drugs to treat gender dysphoria 
  • BSWHP offers all gender affirming hormonal treatments either as pharmacy or medical benefit options with or without a prior authorization process for medical necessity (e.g., GnRH agonists, testosterones, estrogens, progestins, spironolactone).

Preventive Care medications to promote better health as recommended by ACA.  The following drugs and supplements are covered without cost-share, even if over-the-counter, are prescribed by a healthcare professional and filled at a network pharmacy.

Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a healthcare professional and filled by a network pharmacy. These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

Medical Foods (Pharmacy):  Medical foods are available to members for the treatment and/or management for PKU and for the indication of inborn errors of metabolism.  This is available through the pharmacy benefit at either a Tier 2 or Tier 3 cost share for 30 day supply.  Medical foods offered on an OTC basis, or through internet sites, are not covered.

• $10 (Preferred Generic)  Retail (30-day supply)
• 30% coinsurance, up to a maximum of a $75 copay (Preferred Brand) Retail (30-day supply)
• 50% coinsurance, up to a maximum of a $200 copay (Non-Preferred Brand) Retail (30-day supply)
• $400 (Preferred Generic and Brand Specialty drug) Retail (30-day supply)
• $600 (Non-Preferred Specialty drug)  Retail (30-day supply)

Note Plan benefit: Some drugs do not have a generic equivalent, in this case, the brand name copay is required.   

• $12 (Preferred Generic)  Retail (30-day supply)
• $60 (Preferred Brand) Retail (30-day supply)
• $120 (Non-Preferred Brand)  Retail (30-day supply)
• $400 (Preferred Generic and Brand Specialty drug) Retail (30-day supply)
• $600 (Non-Preferred Specialty drug) Retail 30-day supply

Note Plan benefit: Some drugs do not have a generic equivalent, in this case, the brand name copay is required.  

• Maintenance drugs are allowed up to a 90-day supply if obtained through a Baylor Scott and White Pharmacy or participating pharmacy or when using the mail-order prescription service.
• Specialty drugs are limited to a 30-day supply.

• $25 (Preferred Generic) Maintenance (90-day supply)
• Lesser of $187.50 copay or 30% coinsurance (Preferred Brand) Maintenance (90-day supply)
• Lesser of $500 copay or 50% coinsurance (Non-Preferred Brand) Maintenance (90-day supply)

• $30 (Preferred Generic) Maintenance (90-day supply)
• $150 (Preferred Brand) Maintenance (90-day supply)
• $300 (Non-Preferred Brand) Maintenance (90-day supply)

Contraceptive drugs and devices as listed in the ACA/HRSA site.  Contraceptive coverage is available at no cost to FEHB members.  The contraceptive benefit includes at least one option in all methods of contraception (as well as the screening, education, counseling, and follow-up care).  Any contraceptive that is not already available without cost sharing on the formulary can be accessed through the contraceptive exceptions process described below.

• Non-formulary branded contraceptives can be requested without cost-sharing through the exception process.  These will be covered without cost sharing if using the requested product for contraception and are medically necessary.
• Reimbursement for over-the-counter contraceptives can be submitted by utilizing the direct medical reimbursement claim process if a valid prescription is first obtained from a prescriber to provide coverage.

Refer to the list of Women's contraception drugs and devices that are covered at $0 copay at: https://www.bswhealthplan.com/fehb/Pages/default.aspx#pharmacy

Morning after pill (this is an over-the-counter emergency contraceptive drug)

$0 copay

Morning after pill is covered at no cost to the member if prescribed by a physician and purchased at a network pharmacy.

$0 copay

Morning after pill is covered at no cost to the member if prescribed by a physician and purchased a a network pharmacy.

Plan exclusions:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies 
• Nonprescription medications unless specifically indicated elsewhere
• A prescription that has an over the counter alternative

All charges

All charges

Fertility Drugs: medication coverage under the pharmacy benefit for fertility and assisted reproductive technology (ART) procedures, including in vitro fertilization (IVF). Includes coverage for oral and injectable medications in the following categories: oral ovulation induction, gonadotropins, follicle stimulating hormones, and progestins.

30% of Charges. Deductible does not apply. Limit of up to three (3) cycles for IVF drugs.

50% of Charges. Deductible does not apply. Limit of up to three (3) cycles for IVF drugs. 

We only cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury.

We have no other dental benefits.

$50 office visit copay with a specialist

$50 office visit copay with a specialist

Plan exclusions: Routine/Restorative

All charges

Under the flexible benefits option, we determine the most effective way to provide services.

• We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement, regular contract benefits will continue.
• Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
• By approving an alternative benefit, we do not guarantee you will get it in the future.
• The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
• If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
• Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process see page (Applies to printed brochure only).

For any of your health concerns, 24 hours a day, 7 days a week, you may call and talk with a registered nurse who will discuss treatment options and answer your health questions. Our nurses can give you information about how to take care of yourself at home or can help you decide if an appointment, an urgent care visit or an emergency room visit is best for your symptoms. If you want to talk to a nurse, call 800-724-7037. The nurse advice line is available to all BSWHP members.

BSWHP utilizes a toll-free TTY number 711 to assist with communication services for Members with hearing or speech difficulties.

Baylor Scott & White Health Plan will help you get an appointment when you need to be seen!

If you are having difficulty getting an appointment to see one of our participating providers, please call us. Our personalized service will get you an appointment to see a clinician when you need to be seen. Please call us at  844-633-5325.

In an effort to improve communication with non-English speaking members, BSWHP uses the interpretive services of CQfluency.  Members do not have to call a special line for this service. When contacting BSWHP, Members may notify the Health Services (HSD) staff and/or Customer Advocates of their primary language and the call will be completed with the help of a CQfluency interpreter at no charge to the Member. BSWHP HSD staff follows established internal BSWHP policies related to the provision of interpretive services for BSWHP members.

An exhaustive list of wellness programs can be found at https://www.bswhealthplan.com/fehb/pages/default.aspx under the Health and Wellness heading.

- WebMD digital wellness platform

The WebMD digital wellness platform encourages members to be healthy, while providing personal health support for various health conditions and health risks.

- Wondr Health

Have you ever wondered why some people can eat the foods they love and not gain weight?  Wondr Health reveals the secret sauce behind the unexpected concept through behavioral science.

- Wellness Webinar series

BSWHP has free health education opportunities you can access from the comfort of home, your workplace, or wherever you may be.  There's a series of topics that include nutrition, happiness, and other health topics.  Webinars take place midday, so grab your lunch and plan to join us!

- Be Well newsletter

Be Well is a collection of news, tips and reminders designed to help you and your family make the most of your wellness benefits and live a healthy lifestyle.

Baylor Scott & White Health Plan provides the following services for expectant mothers during pregnancy and for one year after birth:

Access to a nurse 24/7 during pregnancy with use of our nurse line found on the ID card

In-home support for higher risk conditions including: diabetes, hypertension, and severe nausea

Depression screening following delivery

Planning for returning to work

Members can obtain these services by contacting Customer Service at 844-633-5325

In most cases, providers and facilities file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, contact us at 844-633-5325, or at our website at https://bswhealthplan.com/fehb.

When you must file a claim – such as for services you received outside the Plan’s service area – submit it on the CMS-1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:

• Covered member’s name, date of birth, address, phone number and ID number
• Name and address of the provider or facility that provided the service or supplies
• Dates you received the services or supplies
• Diagnosis
• Type of each service or supply
• The charge for each service or supply
• A copy of the explanation of benefits, payments, or denial from any primary payer – such as the Medicare Summary Notice (MSN)
• Receipts, if you paid for your services

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills. Submit your claims to:

Baylor Scott & White Health Plan
Attn: Claims Department
1206 West Campus Drive
Temple, TX 76502

Submit your claims to:

Baylor Scott and White Health Plan
Attn: Pharmacy Claims Department
1206 West Campus Drive
Temple, TX 76502

Submit your claims to:

Baylor Scott & White Health Plan
Attn: Claims Department
1206 West Campus Drive
Temple, TX 76502

Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.

We will notify you of our decision within 30 days after we receive your post-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you before the expiration of the original 30-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.

You may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us. For urgent care claims, we will permit a healthcare professional with knowledge of your medical condition to act as your authorized representative without your express consent. For the purposes of this section, we are also referring to your authorized representative when we refer to you.

If you live in a county where at least 10% of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language. You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as phone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the healthcare provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes.

Ask us in writing to reconsider our initial decision. You must:

• Write to us within 6 months from the date of our decision; and
• Send your request to us at Baylor Scott & White Health Plan, Attn: Customer Service Department, 1206 West Campus Drive, Temple, TX 76502; and
• Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and
• Include copies of documents that support your claims, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.
• Include your email address (optional for member), if you would like to receive our decision via email. Please note that by giving us your email, we may be able to provide our decision more quickly.

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision. We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date. However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration. You may respond to that new evidence or rationale at the OPM review stage described in step 4.

In the case of a post-service claim, we have 30 days from the date we receive your request to:

• Pay the claim or
• Write to you and maintain our denial or
• Ask you or your provider for more information

You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.

If we do not receive the information within 60 days we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.

If you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within:

• 90 days after the date of our letter upholding our initial decision; or
• 120 days after you first wrote to us -- if we did not answer that request in some way within 30 days; or
• 120 days after we asked for additional information.

Write to OPM at: United States Office of Personnel Management, Healthcare, and Insurance, Federal Employee Insurance Operations, Health Insurance 3, 1900 E Street, NW, Washington, DC 20415-3630.

Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
• Copies of documents that support your claims, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
• Copies of all letters you sent to us about the claim;
• Copies of all letters we sent to you about the claim; and
• Your daytime phone number and the best time to call;
• Your email address, if you would like to receive OPM’s decision via email. Please note that by providing your email address, you may receive OPM’s decision more quickly.

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request. However, for urgent care claims, a healthcare professional with knowledge of your medical condition may act as your authorized representative without your express consent.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision or notify you of the status of OPM's review within 60 days. There are no other administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to file a lawsuit. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays healthcare expenses without regard to fault. This is called "double coverage."

When you have double coverage, one plan normally pays its benefits in full as the primary payor or and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners' (NAIC) guidelines. For more information on NAIC rules regarding the coordinating of benefits, visit our website at https://bswhealthplan.com/fehb.

When we are the primary payor, we will pay the benefits described in this brochure.

When we are the secondary payor, we will determine our allowance. After the primary plan processes the benefit, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance.

TRICARE is the healthcare program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. IF TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under TRICARE or CHAMPVA.

Every job-related injury or illness should be reported as soon as possible to your supervisor.  Injury also means any illness or disease that is caused or aggravated by the employment as well as damage to medical braces, artificial limbs and other prosthetic devices.  if you are a federal or postal employee, ask your supervisor to authorize medical treatment by use of form CA-16 before you obtain treatment.  If your medical treatment is accepted by the Dept. of Labor Office of Workers" Compensation (OWCP), the provider will be compensated by OWCP.  If your treatment is determined not job-related, we will process  your benefit according to the terms of this plan, including use of in-network providers.  Take form CA-16 and form OWCP-1500/HCFA-1500 to your provider, or send it to your provider as soon as possible after treatment, to avoid complications about whether your treatment is covered by this plan or by OWCP.

We do not cover services that:

• You (or a covered family member) need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar Federal or State agency determines they must provide; or
• OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

When you have this Plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these State programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the State program.

We do not cover services and supplies when a local, State, or Federal government agency directly or indirectly pays for them.

We are entitled to reimbursement to the extent of the benefits we have paid or provided in connection with your injury or illness. However, we will cover the cost of treatment that exceeds the amount of the payment you received.

Reimbursement to us out of the payment shall take first priority (before any of the rights of any other parties are honored) and is not impacted by how the judgment, settlement, or other recovery is characterized, designated, or apportioned. Our right of reimbursement is not subject to reduction based on attorney fees or costs under the "common fund" doctrine and is fully enforceable regardless of whether you are "made whole" or fully compensated for the full amount of damages claimed.

We may, at our option, choose to exercise our right of subrogation and pursue a recovery from any liable party as successor to your rights.

If you do pursue a claim or case related to your injury or illness, you must promptly notify us and cooperate with our reimbursement or subrogation efforts.

Some FEHB plans already cover some dental and vision services. When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage. FEDVIP coverage pays secondary to that coverage. When you enroll in a dental and/or vision plan on BENEFEDS.com or by phone at 1-877-888-3337, (TTY 1-877-889-5680) you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application.

If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:

• Routine care costs - costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient's condition, whether the patient is in a clinical trial or is receiving standard therapy.
• Extra care costs - costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient's routine care.
• Research costs - costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This plan does not cover these costs.

For more detailed information on "What is Medicare?" and "Should I Enroll in Medicare?"  please contract Medicare at 1-800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048) or at www.medicare.gov.

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share.

All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B when Medicare is primary. This is true whether or not they accept Medicare.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

Claims process when you have the Original Medicare Plan - You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payor, we process the claim first. When Original Medicare is the primary payor, Medicare processes your claim first.

In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 844-633-5325 or see our website at https://bswhealthplan.com/fehb.

We waive all costs if the Original Medicare Plan is your primary payor - We will waive some out-of-pocket costs as follows:

• Medical services and supplies provided by physicians and other healthcare professionals.

We do not waive any costs if the Original Medicare Plan is your primary payor.

Please review the following examples which illustrate your cost share if you are enrolled in Medicare Part B. If you purchase Medicare Part B, your provider is in our network and participates in Medicare, then we waive some costs because Medicare will be the primary payor.

Benefit Description: Deductible
Standard Option You Pay Without Medicare: $300
Standard Option You Pay With Medicare Part B: $0

Benefit Description: Out of Pocket Maximum
Standard Option You Pay Without Medicare: $5,500
Standard Option You Pay With Medicare Part B: $5,500

Benefit Description: Part B Premium Reimbursement Offered
Standard Option You Pay Without Medicare: N/A
Standard Option You Pay With Medicare Part B: N/A

Benefit Description: Primary Care Provider
Standard Option You Pay Without Medicare: $25
Standard Option You Pay With Medicare Part B: $0

Benefit Description: Specialist
Standard Option You Pay Without Medicare: $50
Standard Option You Pay With Medicare Part B: $0

Benefit Description: Inpatient Hospital
Standard Option You Pay Without Medicare: 10% Coinsurance
Standard Option You Pay With Medicare Part B: $0

Benefit Description: Outpatient Hospital
Standard Option You Pay Without Medicare: 10% Coinsurance
Standard Option You Pay With Medicare Part B: $0

Benefit Description: Incentives Offered
Standard Option You Pay Without Medicare: N/A
Standard Option You Pay With Medicare Part B: N/A

Benefit Description: Deductible
Basic Option You Pay Without Medicare: $1,500
Basic Option You Pay With Medicare Part B: $0

Benefit Description: Out of Pocket Maximum
Basic Option You Pay Without Medicare: $6,000
Basic Option You Pay With Medicare Part B: $6,000

Benefit Description: Part B Premium Reimbursement Offered
Basic Option You Pay Without Medicare: N/A
Basic Option You Pay With Medicare Part B: N/A

Benefit Description: Primary Care Physician
Basic Option You Pay Without Medicare: $25
Basic Option You Pay With Medicare Part B: $0

Benefit Description: Specialist
Basic Option You Pay Without Medicare: $50
Basic Option You Pay With Medicare Part B: $0

Benefit Description: Inpatient Hospital
Basic Option You Pay Without Medicare: 20% Coinsurance
Basic Option You Pay With Medicare Part B: $0

Benefit Description: Outpatient Hospital
Basic Option You Pay Without Medicare: 20% Coinsurance
Basic Option You Pay With Medicare Part B: $0

Benefit Description: Incentives Offered
Basic Option You Pay Without Medicare: N/A
Basic Option You Pay With Medicare Part B: N/A

You can find more information about how our plan coordinates benefits with Medicare online at https://bswhealthplan.com/fehb.

You must tell us if you or a covered family member has Medicare coverage, and let us obtain information about services denied or paid under Medicare if we ask. You must also tell us about other coverage you or your covered family members may have, as this coverage may affect the primary/secondary status of this Plan and Medicare.

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country.

To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (800-633-4227), (TTY: 877-486-2048) or at www.medicare.gov.

If you enroll in a Medicare Advantage plan, the following options are available to you:

This Plan and our Medicare Advantage plan: You may enroll in our plan's Medicare Advantage plan and also remain enrolled in our FEHB plan.

This Plan and another plan's Medicare Advantage plan: You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan's network and/or service area (if you use our Plan providers). However, we will not waive any of our copayments, coinsurance, or deductibles. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage plan premium.) For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan's service area.

When we are the primary payor, we process the claim first. If you enroll in Medicare Part D and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB plan.

• You have FEHB coverage on your own or through your spouse who is also an active employee

• You have FEHB coverage through your spouse who is an annuitant

• It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)

• It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD

• This Plan was the primary payor before eligibility due to ESRD (for 30-month coordination period)

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

• Medicare based on ESRD (for the 30-month coordination period)

• Medicare based on ESRD (after the 30-month coordination period)

An authorization by you (the enrollee or covered family member) that is approved by us (the Carrier), for us to issue payment of benefits directly to the provider.

• We reserve the right to pay you directly for all covered services. Benefits payable under the contract are not assignable by you to any person without express written approval from us, and in the absence of such approval, any assignment shall be void.
• Your specific written consent for a designated authorized representative to act on your behalf to request reconsideration of a claim decision (or, for an urgent care claim, for a representative to act on your behalf without designation) does not constitute an Assignment.
• OPM’s contract with us, based on federal statute and regulation, gives you a right to seek judicial review of OPM's final action on the denial of a health benefits claim but it does not provide you with authority to assign your right to file such a lawsuit to any other person or entity.  Any agreement you enter into with another person or entity (such as a provider, or other individual or entity) authorizing that person or entity to bring a lawsuit against OPM, whether or not acting on your behalf, does not constitute an Assignment, is not a valid authorization under this contract, and is void.

January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application.

• Routine care costs – costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s cancer, whether the patient is in a clinical trial or is receiving standard therapy
• Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care
• Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This plan does not cover these costs.

See Section 4, (Applies to printed brochure only).

 See Section 4, (Applies to printed brochure only).

 See Section 4, (Applies to printed brochure only).

Care we provide benefits for, as described in this brochure.

“Custodial Care” means care designed principally to assist an individual in engaging in the activities of daily living, or services which constitute personal care, such as help in walking and getting in and out of bed; assistance in bathing, dressing, feeding and using the toilet; preparation of special diets; and supervision of medication, which can usually be self-administered and which does not entail or require the continuing attention of trained medical or other paramedical personnel. Custodial Care is normally, but not necessarily, provided in a nursing home, convalescent home, or rest home or similar institution.

 See Section 4, (Applies to printed brochure only).

“Experimental” or “Investigational” means, in the opinion of the Medical Director, Treatment that has not been proven successful in improving the health of patients.

A physician or other healthcare professional licensed, accredited or certified to perform specified health services consistent with state law.

The inability to carry a pregnancy to live birth without the use of birth control after unprotected sexual intercourse / failure of egg and sperm contact and uterine implantation without medical assistance after 12 months if under age 35, or 6 months if age 35 years or older. Infertility may also be justified based on the individual having a medical or other recognized condition as a cause of infertility.  

Those Health Care Services which, in the opinion of Member's Primary Care Provider or Referral Physician, whose opinions are subject to the review, approval or disapproval, and actions of the Medical Director or the Quality Assurance Committee in their appointed duties, are:

1. Essential to preserving the health of Member; and
2. Consistent with the symptoms or diagnosis and Treatment of the Member's condition, disease, ailment or injury; and
3. Appropriate with regard to standards of good medical practice within the surrounding community; and
4. Not solely for the convenience of the Member, Member's Physician, Hospital, or other health care provider; and
5. The most appropriate supply or level of service which can be safely provided to the Member.

Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways. We determine our allowance as follows:

Our plan allowance is the amount our contracted providers have agreed to accept as payment in full.  For emergency care received at any doctor’s office, outside our Plan’s service area, our Plan’s allowance is the amount BSWHP has determined to be the allowable prevailing charge for a particular professional service in the geographical area in which the service is performed.

You should also see Important Notice About Surprise Billing - Know Your Rights in Section 4 that describes your protections against surprise billing under the No Surprises Act.

Those claims (1) that require precertification, prior approval, or a referral and (2) where failure to obtain precertification, prior approval, or a referral results in a reduction of benefits.

A carrier's pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, and the terms of the carrier's health benefits plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided. The right of reimbursement is cumulative with and not exclusive of the right of subrogation.

A carrier's pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier's health benefits plan.

An unexpected bill you receive for:

• emergency care – when you have little or no say in the facility or provider from whom you receive care, or for
• non-emergency services furnished by nonparticipating providers with respect to patient visits to participating health care facilities, or for
• air ambulance services furnished by nonparticipating providers of air ambulance services.

A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:

• Waiting could seriously jeopardize your life or health;
• Waiting could seriously jeopardize your ability to regain maximum function; or
• In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Urgent care claims usually involve Pre-service claims and not Post-service claims. We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at 844-633-5325. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Us and We refer to Baylor Scott & White Health Plan

Primary Care Provider (PCP) Office visit copay: $25

First Adult non-preventive PCP Copay:  $0

PCP Copay for dependents ages 0-18:  $0

Specialist Office visit copay: $50 

27

10% coinsurance*

45

10% coinsurance*

46

10% coinsurance*

47

• Outpatient - $25 per visit
• 10% coinsurance*

49

• $10 (Preferred Generic) 30-day supply
• 30% coinsurance, up to a maximum of $75 copay (Preferred Brand) 30-day supply
• 50% coinsurance, up to a maximum of a $200 copay. (Non-Preferred Brand ) 30-day supply
• $400 (Preferred Generic and Brand Specialty drug) 30-day supply
• $600 (Non-Preferred Specialty drug) 30-day supply

51

• $25 (Preferred Generic) 90-day supply
• Lesser of $187.50 copay or 30% coinsurance (Preferred Brand) 90-day supply
• Lesser of $500 copay or 50% coinsurance $375 (Non-Preferred brand) 90-day supply

53

$50 outpatient

55

$50 specialist copay

34

$5,500 Self Only, $11,000 Self Plus One , $11,000 Self and Family

24

Primary Care Provider (PCP) Office visit copay: $25

First Adult non-preventive PCP Copay:  $0

PCP Copay for dependents ages 0-18:  $0

Specialist Office visit copay: $50 

27

20% coinsurance*

45

20% coinsurance*

46

20% coinsurance*

47

• Inpatient - 20% coinsurance*
• Outpatient - $25 per visit

49

• $12 (Preferred Generic) 30-day supply
• $60 (Preferred Brand) 30-day supply
• $120 (Non-Preferred Brand) 30-day supply
• $400 (Preferred Generic and Brand Specialty drug) 30-day supply
• $600 (Non-Preferred Specialty drug) 30-day supply

51

• $30 (Preferred Generic) 90-day supply
• $150 (Preferred Brand) 90-day supply
• $300 (Non-Preferred Brand) 90-day supply 

53

$50 outpatient

55

$50 specialist copay

34

$6,000 Self Only, $12,000 Self Plus One, $12,000 Self and Family

24