Page numbers referenced within this brochure apply only to the printed brochure

Baylor Scott & White Health Plan

https://fehb.swhp.org
Customer Service 844-633-5325

2022



IMPORTANT:
  • Rates
  • Changes for 2022
  • Summary of Benefits
  • Accreditations
A Health Maintenance Organization (Standard and Basic Options)

This plan's health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides.  See page 9. This plan is accredited. See page 13. 

Standard Option: Serving the North, Central, and West Texas Areas

Basic Option: Serving the North and Central Texas Areas


     

Enrollment in these plans is limited.

You must live or work in the Baylor Scott and White Health Plan geographic service area based upon the plan option selected. Please see Section 1, page 14, under Eligibility Service Area for a list of counties for our Standard and Basic plan options. 

Enrollment Codes for the Standard Plan in 
Central and West Texas:
A84 Standard Option - Self Only
A86 Standard Option - Self Plus One
A85 Standard Option - Self and Family

Enrollment Codes for the Standard Plan in 
North Texas:
P84 Standard Option - Self Only
P86 Standard Option - Self Plus One
P85 Standard Option - Self and Family

Enrollment Codes for the Basic Plan in 
Central Texas:
A81 Basic Option - Self Only
A83 Basic Option - Self Plus One
A82 Basic Option - Self and Family

Enrollment Codes for the Basic Plan in 
North Texas:
P81 Basic Option - Self Only
P83 Basic Option - Self Plus One
P82 Basic Option - Self and Family

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Important Notice

Important Notice from Baylor Scott & White Health Plan About
Our Prescription Drug Coverage and Medicare

 

The Office of Personnel Management (OPM) has determined that BSWHP's prescription drug coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all plan participants and is considered Creditable Coverage. This means you do not need to enroll in Medicare Part D and pay extra for prescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as long as you keep your FEHB coverage.

However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will coordinate benefits with Medicare.

Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program.

Please be advised

If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that is at least as good as Medicare’s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1 percent per month for every month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug coverage, your premium will always be at least 19 percent higher than what many other people pay. You will have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the next Annual Coordinated Election Period (October 15 through December 7) to enroll in Medicare Part D.

Medicare’s Low Income Benefits

For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA) online at www.socialsecurity.gov, or call the SSA at 800-772-1213, (TTY:  800-325-0778). 

You can get more information about Medicare prescription drug plans and the coverage offered in your area from these places:

  • Visit www.medicare.gov for personalized help.
  • Call 800-MEDICARE 800-633-4227, TTY 877-486-2048.



Table of Contents

(Page numbers solely appear in the printed brochure)




Introduction

This brochure describes the benefits of FEHB under contract (CS 2942) between Scott & White Health Plan and the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law.  Customer service may be reached at 844-633-5325 or through our website: https://fehb.swhp.org. The address for SWHP administrative offices is:

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

This brochure is the official statement of benefits. No verbal statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure.  If you are enrolled in Self Plus One or Self and Family coverage, each eligible family member is also entitled to these benefits.  You do not have a right to benefits that were available before January 1, 2022, unless the benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2022 and changes are summarized on page 16. Rates are shown at the end of this brochure.




Plain Language

All FEHB brochures are written in plain language to make them easy to understand. Here are some examples:

  • Except for necessary technical terms, we use common words. For instance, "you" means the enrollee and each covered family member, "we" means BSWHP.
  • We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States Office of Personnel Management. If we use others, we tell you what they mean.
  • Our brochure and other FEHB plans’ brochures have the same format and similar descriptions to help you compare plans.



Stop Health Care Fraud!

Fraud increases the cost of healthcare for everyone and increases your Federal Employees Health Benefits Program premium.

OPM’s Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud – Here are some things that you can do to prevent fraud:

  • Do not give your plan identification (ID) number over the phone or to people you do not know, except for your healthcare providers, authorized health benefits plan, or OPM representative.
  • Let only the appropriate medical professionals review your medical record or recommend services.
  • Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
  • Carefully review explanations of benefits (EOBs) statements that you receive from us.
  • Periodically review your claim history for accuracy to ensure we have not been billed for services you did not receive.
  • Do not ask your doctor to make false entries on certificates, bills, or records in order to get us to pay for an item or service.

If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:

  • Call the provider and ask for an explanation. There may be an error.
  • If the provider does not resolve the matter, call us at 844-633-5325 and explain the situation.
  • If we do not resolve the issue

CALL - THE HEALTHCARE FRAUD HOTLINE
877-499-7295
OR go to www.opm.gov/our-inspector-general/hotline-to-report-fraud-waste-or-abuse/
complaint-form/

The online reporting form is the desired method of reporting fraud in order to ensure accuracy and a quicker response time.

You can also write to:

United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington, DC; 20415-1100

Do not maintain as a family member on your policy:

  • Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise)
  • Your child age 26 or over (unless they are disabled and incapable of self-support prior to age 26)

A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB Plan.

  • If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary Continuation of Coverage (TCC).
  • Fraud or intentional misrepresentation of material fact is prohibited under the Plan. You can be prosecuted for fraud and your agency may take action against you. Examples of fraud include falsifying a claim to obtain FEHB benefits, trying to or obtaining service or coverage for yourself or for someone else who is not eligible for coverage, or enrolling in the Plan when you are no longer eligible.
  • 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 by your provider for services received. 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 is no longer eligible to use your health insurance coverage.



Discrimination is Against the Law

Discrimination is Against the Law

Baylor Scott and White Health Plan complies with applicable Federal civil rights laws, including Title VII of the Civil Rights Act of 1964.

You can also file a civil rights complaint with the Office of Personnel Management by mail at: Office of Personnel Management Healthcare and Insurance Federal Employee Insurance Operations, Attention: Assistant Director FEIO, 1900 E Street NW, Suite 3400 S, Washington, DC 20415-3610.




Preventing medical mistakes

Medical mistakes continue to be a significant cause of preventable deaths within the United States.  While death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional treatments. Medical mistakes and their consequences also add significantly to the overall cost of healthcare.  Hospitals and healthcare providers are being held accountable for the quality of care and reduction of medical mistakes by their accrediting bodies.  You can also improve the quality and safety of your own healthcare and that of your family members by learning more about and understanding your risks.  Take these simple steps:

  1. Ask questions if you have doubts or concerns.
    • Ask questions and make sure you understand the answers.
    • Choose a doctor with whom you feel comfortable talking.
    • Take a relative or friend with you to help you take notes, ask questions, and understand answers.
  2. Keep and bring a list of all the medications you take.
    • Bring the actual medication or give your doctor and pharmacist a list of all the medications and dosage that you take, including non-prescription (over-the-counter) medications and nutritional supplements.
    • Tell your doctor and pharmacist about any drug, food, and other allergies you have, such as to latex.
    • Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your doctor or pharmacist says.
    • Make sure your medication is what the doctor ordered. Ask your pharmacist about the medication if it looks different than you expected.
    • Read the label and patient package insert when you get your medication, including all warnings and instructions.
    • Know how to use your medication. Especially note the times and conditions when your medication should and should not be taken.
    • Contact your doctor or pharmacist if you have any questions.
    • Understand both the generic and brand names of your medication.  This helps to ensure you do not receive double dosing from taking both a generic and a brand.  It also helps prevent you from taking a medication to which you are allergic.
  3. Get the results of any test or procedure.
    • Ask when and how you will get the results of tests or procedures.   Will it be in person, by phone, mail, through the Plan or Provider's portal?
    • Don’t assume the results are fine if you do not get them when expected.  Contact your healthcare provider and ask for your results.
    • Ask what the results mean for your care.
  4. Talk to your doctor about which hospital or clinic is best for your health needs.
    • Ask your doctor about which hospital or clinic has the best care and results for your condition if you have more than one hospital or clinic to choose from to get the healthcare you need.
    • Be sure you understand the instructions you get about follow-up care when you leave the hospital or clinic.
  5. Make sure you understand what will happen if you need surgery.
    • Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.
      • Ask your doctor, "Who will manage my care when I am in the hospital?"
    • Ask your surgeon:
      • "Exactly what will you be doing?"
      • "About how long will it take?"
      • "What will happen after surgery?"
      • "How can I expect to feel during recovery?"
    • Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reactions to anesthesia, and any medications or nutritional supplements you are taking.

Patient Safety Links

For more information on patient safety, please visit:

    • www.jointcommission.org/speakup.aspx.  The Joint Commission's Speak UpTM patient safety program.
    • www.jointcommission.org/topics/patient_safety.aspx.  The Joint Commission helps healthcare organizations to improve the quality and safety of the care they deliver.
    • www.ahrq.gov/patients-consumers/. The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality healthcare providers and improve the quality of care you receive.
    • www.bemedwise.org. The National Council on Patient Information and Education is dedicated to improving communication about the safe, appropriate use of medications.
    • www.leapfroggroup.org. The Leapfrog Group is active in promoting safe practices in hospital care.
    • www.ahqa.org. The American Health Quality Association represents organizations and healthcare professionals working to improve patient safety.

Preventable Healthcare Acquired Conditions ("Never Events")

When you enter the hospital for treatment of one medical problem, you do not expect to leave with additional injuries, infections or other serious conditions that occur during the course of your stay. Although some of these complications may not be avoidable, patients do suffer from injuries or illnesses that could have been prevented if doctors or the hospital had taken proper precautions.  Errors in medical care that are clearly identifiable, preventable and serious in their consequences for patients, cn indicate a significant problem in the safety and credibility of a healthcare facility.  These conditions and errors are sometimes called "Never Events" or "Serious Reportable Events."

We have a benefit payment policy that encourages hospitals to reduce the likelihood of hospital-acquired conditions such as certain infections, severe bedsores, and fractures, and to reduce medical errors that should never happen.  When such an event occurs, neither you nor your FEHB plan will incur costs to correct the medical error.  

You will not be billed for inpatient services related to the treatment of specific hospital-acquired conditions or for inpatient services needed to correct Never Events if you use BSWHP contracted providers. This policy helps to protect you from preventable medical errors and improve the quality of care you receive.




FEHB Facts

Coverage information




TermDefinition
  • No pre-existing condition limitation
We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled.
  • Minimum essential coverage (MEC)

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.

  • Minimum value standard

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.

  • Where you can get information about enrolling in the FEHB Program

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, and give you, brochures for other plans 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.

  • Types of coverage available for you and your family

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 carrier to obtain a Certificate of Creditable Coverage (COCC) or to add a dependent when there is already family Coverage.

Contact your employing or retirement office if you are changing from Self to Self Plus One or Self and Family or to add a newborn if you currently have a Self Only plan.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits, nor will we. Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches 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 member coverage

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 ember 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.

  • Children’s Equity Act

OPM has implemented 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.

  • When benefits and premiums start

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 2022 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 2021 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
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).



When you lose benefits




TermDefinition
  • When FEHB coverage ends

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).

  • Upon divorce

If you are divorced from a Federal employee or annuitant, you may not continue to get benefits 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 RI 70-5, the Guide to Federal Benefits for Temporary Continuation of Coverage and Former Spouse Enrollees, or other information about your coverage choices. You can also download the guide from OPM’s website, www.opm.gov/healthcare-insurance/healthcare/plan-information/.  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.

  • Temporary Continuation of Coverage (TCC)

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). The Affordable Care Act (ACA) did not eliminate TCC or change the TCC rules. 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, if you are a covered dependent child and you turn 26, etc.

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 new kind of 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.

Converting to individual 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 https://fehb.swhp.org.

  • Health Insurance Marketplace

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.




Section 1. How This Plan Works

This Plan is a health maintenance organization (HMO). OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards.  Baylor Scott and White Health Plan holds the following accreditation: National Committee for Quality Assurance (NCQA).  To learn more about this plan’s accreditation, please visit the following website: www.ncqa.org.

We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. We are solely responsible for the selection of these providers in your area. Contact us for a copy of our most recent provider directory.  We give you a choice of enrollment in a Standard Option and a Basic Option plan.

HMOs, emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment. 

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You pay only the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may have to submit claim forms.

You should join an HMO because you prefer the plan’s benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other providers will be available and/or remain under contract with us. 

General features of our Standard and Basic Options

We have Open Access benefits

Our HMO offers Open Access benefits. This means you can receive covered services from a participating provider without a required referral from your primary care physician or by another participating provider in the network.

How we pay providers

We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments, coinsurance, deductibles, and non-covered services and supplies).

Health education resources and account management tools

Health education resources and account management tools are available on our website at fehb.swhp.org.

  • Wellness programs are available online or by calling Customer Service at 844-633-5325.
  • You can access your claims and explanations of benefits (EOBs) by visiting https://fehb.swhp.org and logging in to the BSWHP member portal.
  • You can view, display and order ID cards.

Your rights and responsibilities

OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us, our networks, and our providers. OPM’s FEHB website www.opm.gov/healthcare-insurance/ lists the specific types of information that we must make available to you. Some of the required information is listed below. 

  • Scott and White Health Plan began operation in January of 1982 as a not-for-profit Health Maintenance Organization (HMO).
  • Scott and White Health Plan is a privately owned, not-for-profit community-based health maintenance organization and does not include any partners.

You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan.  You can view the complete list of these rights and responsibilities by visiting our website, https://fehb.swhp.org. 

If you want more information about us, call 844-633-5325, or write to Baylor Scott and White Health Plan, 1206 West Campus Drive, Temple, TX 76502. You may also visit our website at https://fehb.swhp.org.

By law, you have the right to access your protected health information (PHI).  For more information regarding access to PHI, visit our website at https://fehb.swhp.org to obtain our Notice of Privacy Practices. You can also contact us to request that we mail a copy regarding access to PHI.

Your medical and claims records are confidential

We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.

Service Area:

The Standard Option utilizes the BSWHP HMO Network.

The Basic Option utilizes the BSW Preferred HMO Network.

Standard Option Eligibility Area

To enroll in this Option, you must live in or work in one of the counties listed below. This is where our provider's practice.  Baylor Scott and White Health Plan has two service areas for the FEHB program.  Our service area includes Central and West Texas, and North Texas.

The following counties comprise our Central and West Texas service area for this option:

Austin, Bastrop, Bell, Blanco, Bosque, Brazos, Burleson, Burnet, Caldwell, Coke, Coleman, Concho, Coryell, Crockett, Falls, Fayette, Freestone, Grimes, Hamilton, Hays, Hill, Irion, Kimble, Lampasas, Lee, Leon, Limestone, Llano, Madison, Mason, McCulloch, McLennan, Menard, Milam, Mills, Reagan, Robertson, Runnels, San Saba, Schleicher, Sterling, Sutton, Tom Green, Travis, Walker, Waller, Washington and Williamson.

The following counties comprise our North Texas service area for this option:

Collin, Dallas, Denton, Ellis, Erath, Hood, Johnson, Rockwall, Somervell, and Tarrant.

Basic Option Eligibility Area

To enroll in this Plan, you must live in or work in one of the counties listed below. This is where our provider's practice.  Baylor Scott and White Health Plan has two service areas for the FEHB program.  Our service area includes Central and West Texas, and North Texas.

The following counties comprise our Central Texas service area for this option:

Bell, Brazos, Burnet, Coryell, Lampasas, Llano, McLennan, Milam, San Saba, Travis, Washington, and Williamson.

The following counties comprise our North Texas service area for this option:

Collin, Dallas, Denton, Ellis, Johnson, Rockwall, and Tarrant.

Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits. We will not pay for any other healthcare services out of our service area unless the services have prior plan approval. 

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.




Section 2. Changes for 2022

Program Wide Changes:

 Effective in 2022, premium rates are the same for Non-Postal and Postal Employees.

Changes to both Basic and Standard Options

  • Your share of the premium rate will increase/decrease/stay the same for Self Only or increase/decrease/stay the same for Self and Family.  See page (Applies to printed brochure only).

Changes to Standard Option 

  • CT Scans, MRI, Angiograms, Myelography, PET Scans, and Stress Tests - The member cost share will be 10% coinsurance per procedure ( subject to the deductible).  The previous cost share was a $150 copay per procedure (subject to the deductible).  See Page (Applies to printed brochure only)

  • Professional services (Diagnostic & Treatment) inpatient hospital and skilled nursing facility - The member cost share will be 10% coinsurance (subject to the deductible).  The previous benefit was a $300 copay per day, and a $1,500 copay maximum per admission (subject to the deductible). See page (Applies to printed brochure only)

  • Inpatient Hospital - The member cost share will be 10% coinsurance ( subject to the deductible).  The previous benefit was a $300 copay per day, and a $1,500 copay maximum per admission (subject to the deductible). See page (Applies to printed brochure only)

  • Inpatient Mental Health and Substance Use Disorder or other covered facility - The member cost share will be 10% coinsurance  (subject to the deductible).  The previous benefit was a $300 copay per day, and a $1,500 copay maximum per admission (subject to the deductible). See page (Applies to printed brochure only)

  • Outpatient Hospital or Ambulatory Surgical Center - The member cost share will be 10% coinsurance (subject to the deductible).  The previous benefit was a $250 copay per visit/procedure (subject to the deductible). See page (Applies to printed brochure only)

  • Emergency Room (Outpatient Hospital), including doctors services - The member cost share will be 10% coinsurance (subject to the deductible).  The previous benefit was a $250 copay per visit. waived if admitted (subject to the deductible). See Page (Applies to printed brochure only)

  • Skilled Nursing Care Facility (Extended Care) - The member cost share will be 10% coinsurance for up to 60 visits per year (subject to the deductible).  The previous benefit was a $300 copay per day, and a $1,500 copay maximum per admission and up to 60 visits per year (subject to the deductible). See page (Applies to printed brochure only)

  • Prescription Drugs - Preferred Brand (retail) - The cost share will be 30% coinsurance, up to a maximum of a $75 copay.  The previous benefit was a $60 copay (30-day supply). See page (Applies to printed brochure only)

  • Prescription Drugs - Non-Preferred Brand (retail) - The member cost share will be 50% coinsurance, up to a maximum of a $200 copay.  The previous benefit was $150 copay (30-day supply). See page (Applies to printed brochure only)

Benefits added for Basic and Standard Options

  • Durable Medical Equipment (DME) (Blood pressure monitor) - We added blood pressure monitors,  Accessible under the DME benefit, the member cost share will be 30% coinsurance (subject to the deductible). See page (Applies to printed brochure only)

  • We added blood pressure monitor training - The member cost share will be a $25 copay per visit to their PCP and a $50 copay per visit to as specialist. See page (Applies to printed brochure only)




Section 3. How you get care

TermDefinition

Identification cards

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 and White Health Plan
1206 West Campus Drive
Temple, TX 76502

You may also request replacement cards through our website: https://fehb.swhp.org.

Where you get covered care

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 physician or by another participating provider in the network.

Balance Billing Protection

 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

Plan providers are physicians and other healthcare professionals in our service area that we contract with to provide covered services to our members.  We credential Plan providers according to national standards. 

We list Plan providers in the provider directory, which we update monthly on our website, https://fehb.swhp.org.

This plan recognizes that transsexual, transgender, and gender-nonconforming members require healthcare delivered by healthcare providers experienced in transgender health.  While gender reassignment surgeons (benefit details found in Section 5(b)) and hormone therapy providers (benefit details found in Section 5(f)) play important roles in preventative care, you should see a primary care provider familiar with your overall health care needs.  Benefits described in this brochure are available to all members meeting medical necessity guidelines.  

Please be aware the Standard Plan option utilizes the BSWHP HMO network and the Basic Plan option utilizes the BSW Preferred HMO network.

Plan facilities

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://fehb.swhp.org.

Please be aware the Standard Plan option utilizes the BSWHP HMO network and the Basic Plan option utilizes the BSW Preferred HMO network.

What you must do to get covered care

Now that you have chosen 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.

Primary care

Members may choose a network primary care physician (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.

Specialty care

All non-emergent medical care must be provided by BSWHP network providers. BSWHP does not require a referral from a primary care physician 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 physician 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.

Hospital care

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.

If you are hospitalized when your enrollment begins

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.

You need prior Plan approval for certain services

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.

Inpatient Hospital Admission Precertification is the process by which – prior to your inpatient hospital admission – we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition.

Other services

For certain services, your physician 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

How to request precertification for an admission or get prior authorization for Other services

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.

Non-urgent care claims

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.

Urgent care claims

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).

Concurrent care claims

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.

The Federal Flexible Spending Account Program - FSAFEDS

  • HealthCare FSA (HCFSA) - Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deducitbles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you and your tax dependents, including adult children (through the end of the calendar year in which they turn 26).
  • FSAFEDS offers paperless reimbursementfor your HCFSA through a number of FEHB and FEDVIP plans.  This means that 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.

Emergency inpatient admission

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.

Maternity care

For each person covered for maternity/childbirth benefits, we will provide inpatient care for the mother and her newborn child in a healthcare facility for a minimum of:

  • 48 hours following an uncomplicated vaginal delivery, and
  • 96 hours following an uncomplicated delivery by cesarean section.

This benefit does not require a covered female who is eligible for maternity/childbirth benefits to (a) give birth in a hospital or other healthcare facility; or (b) remain in a hospital or other healthcare facility for the minimum number of hours following birth of the child.

If a covered mother or her newborn child is discharged before the 48 or 96 hours has expired, we will provide coverage for post delivery care. Post delivery care includes parent education, assistance and training in breast-feeding and bottle-feeding, and the performance of any necessary and appropriate clinical tests. Care will be provided by a physician, registered nurse, or other appropriate licensed healthcare provider, and the mother will have the option of receiving the care at her home, the healthcare provider’s office, or a healthcare facility.

If your treatment needs to be extended

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.

What happens when you do not follow the precertification rules when using non-network facilities

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.

Circumstances beyond our controlUnder certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care.
If you disagree with our pre-service claim decision

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 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.

To reconsider a non-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. 

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.

To reconsider an urgent care claim

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.

To file an appeal with OPMAfter we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure.



Section 4. Your costs for covered services

This is what you will pay out-of-pocket for covered care:



TermDefinition
Cost-sharingCost-sharing is the general term used to refer to your out-of-pocket costs (e.g., coinsurance and copayments) for the covered care you receive.

Copayments

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.

Deductible

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

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

Example: In our Plan, you pay 30% of our allowance for durable medical equipment.

Differences between our Plan allowance and the bill

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.

Your catastrophic protection out-of-pocket maximum

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.

Carryover

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.

When Government Facilities Bill UsFacilities of the Department of Veterans Affairs, the Department of Defense and the Indian Health Services are entitled to seek reimbursement from us for certain services and supplies they provide to you or a family member.  They may not seek more than their governing laws allow. You may be responsible to pay for certain services and charges.  Contact the government facility directly for more information.

Important Notice About Surprise Billing -Know Your Rights

The No Surprises Act (NSA) is a federal law that provides you with protections against "surprise billing" and "balance billing" under certain circumstances.  A surprise bill is an unexpected bill you receive from a nonparticipating health care provider, facility, or air ambulance service for healthcare.  Surprise bills can happen when you receive emergency care - when you have little or no say in the facility or provider from whom you receive care.  They can also happen when you receive non-emergency services at participating facilities, but you receive some care from nonparticipating providers.

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 unexpected 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 www.fehb.swhp.org or contact the health plan at 844-633-5325.




Section 5. Standard Option and Basic Option Benefits (Standard and Basic Option)

See page (Applies to printed brochure only)  for how our benefits changed this year. Page (Applies to printed brochure only) is a benefits summary of the Standard Option.  Page (Applies to printed brochure only) is a benefits summary of the Basic Option.

Make sure that you review the benefits that are available under the option in which you are enrolled.




(Page numbers solely appear in the printed brochure)




Section 5. Standard and Basic Option Benefits Overview (Standard and Basic Option)

This Plan offers both a Standard Option and a Basic Option. Both benefit packages are described in Section 5. Make sure that you review the benefits that are available under the option in which you are enrolled.

The Standard and Basic Option Section 5 is divided into subsections. Please read Important things you should keep in mind at the beginning of the subsections. Also, read the general exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about Standard and Basic Option benefits, contact us at 844-633-5325 or on our website at https://fehb.swhp.org.

Unique features of our Standard Option:

  • Low deductible
  • Low copays or coinsurance for most services
  • No charge for preventive care, lab, x-ray, and preventative mammograms
  • Only $10 for Preferred Generic drugs 
  • BSWHP HMO Network
  • All wellness programs are no charge to members. Programs include:
    • Online Lifestyle Management Programs - Balance, Nourish, Relax, Breathe, Care for Depression, Dream, Care for Your Health, and Care for Pain 
    • Health coaches - direct access to a coach for help on over 65 different diseases and conditions  
    • Shared decision-making - gives the member reliable tools and information to better make decisions with their physicians on treatment options they may have been given related to “preference-sensitive” conditions.
  • 24-hour nurse line included at no charge
  • Customer service available from 7 am to 8 pm Central Time, 7 days a week

Unique features of our Basic Option:

  • Low Premiums
  • Affordable deductible
  • Low copays or coinsurance for most services
  • No charge for preventive care, lab, x-ray, and preventative mammograms
  • Only $12 for Preferred Generic drugs 
  • BSW Preferred HMO Network
  • All wellness programs are no charge to members. Programs include:
    • Online Lifestyle Management Programs - Balance, Nourish, Relax, Breathe, Care for Depression, Dream, Care for Your Health, and Care for Pain 
    • 24-hour nurse line included at no charge

  •  Customer service available from 7 am to 8 pm Central Time, 7 days a week 




Section 5(a). Medical Services and Supplies Provided by Physicians and Other HealthCare Professionals (Standard and Basic Option)

      

Important things you should keep in mind about these benefits.

  • The Standard Option and Basic Option are HMO plans and are only available in certain areas.  Please refer to the Service Area descriptions in Section 1. How this plan works to see if your county is included.
  • The Standard Option utilizes the BSWHP HMO Network.
  • The Basic Option utilizes the BSW Preferred HMO network.
  • Please remember that all benefit is subject to definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Plan physicians must provide or arrange your care.
  •  A facility copay applies to services that appear in this section but are performed in an ambulatory surgical center or the outpatient department of a hospital.
  • For the Standard Option, the calendar year deductible is $300 for Self Only, $600 for Self Plus One or $600 for Self and Family. For the Basic Option, the calendar year deductible is $1,500 for Self Only, $3,000 for Self Plus One or $3,000 for Self and Family. The calendar year deductible is applied to almost all benefits in this Section.  We added “(deductible applies)” to show when the calendar year deductible does apply.
  •  Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.

 




Benefit Description : Diagnostic and treatment services Standard (You Pay)Basic (You Pay)

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

$25 per visit to a primary care physician

$50 per visit to a specialist

$25 per visit to a primary care physician

$50 per visit to a specialist

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)

Benefit Description : Telehealth via E-VisitStandard (You Pay)Basic (You Pay)

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

Benefit Description : Lab, X-ray and other diagnostic testsStandard (You Pay)Basic (You Pay)

Tests, such as:

  • Blood tests
  • Urinalysis
  • Non-routine Pap tests
  • Pathology
  • X-rays
  • Non-routine mammograms
  • Ultrasound
  • Electrocardiogram and EEG
  • BRCA testingPer 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

Nothing

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

10% coinsurance ( deductible applies)

20% per procedure (deductible applies)

Benefit Description : Preventive care benefits, adultStandard (You Pay)Basic (You Pay)

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/DTaP, and human papillomavirus (HPV).  For a complete list of immunizations go to the Centers for Disease Control (CDC) website at

https://www.cdc.gov/vaccines/schedules/

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. Preventative Services Task Force (USPSTF) website at

https://www.uspreventativeservicestaskforce.org

Individual counseling on prevention and reducing health risks

        

Nothing

Nothing

Well woman care such as Pap smears, gonorrhea prophylactic medications to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence.  For a complete list of Well Woman preventative care services please visit the Health and Human Services (HHS) website at

https://www.healthcare.gov/preventative-care-women/

To build your personalized list of preventative services go to https://health.gov/myhealthfinder

Nothing

Nothing

Routine mammogram – covered for women 

Nothing

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.

Note: A complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) is available online at:

www.uspreventativeservicestaskforce.org/Page/Number/uspstf-a-and-b-recommendations/

Nothing

Nothing

Plan exclusions:

• 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

Benefit Description : Preventive care benefits, childrenStandard (You Pay)Basic (You Pay)

Well-child visits, examinations, and other preventative 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. 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 can also find a complete list of preventative case services recommended under the U.S. Preventative Services Task Force (USPSTF) online at

https://www.uspreventativeservicestaskforce.org

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

Nothing

Benefit Description : Maternity careStandard (You Pay)Basic (You Pay)

Complete maternity (obstetrical) care, such as:

  • Prenatal care
  • Screening for gestational diabetes for pregnant women.
  • Delivery
  • Postnatal care

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

Benefit Description : Family PlanningStandard (You Pay)Basic (You Pay)

A range of voluntary family planning services limited to:

  • Voluntary sterilization - Limited to tubal ligation and vasectomy.
  • Surgically implanted contraceptives
  • Injectable contraceptive drugs (such as Depo Provera)
  • Sex education instruction in accordance with medically acceptable standards 
  • Intrauterine devices (IUDs)
  • Diaphrams
  • Contraceptive counseling on an annual basis at no cost share

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

$25 per visit to PCP

$50 per visit to specialist

$25 per visit to PCP

$50 per visit to specialist

Plan exclusions:

  • Reversal of voluntary surgical sterilization
  • Genetic testing and counseling

All charges

All charges

Benefit Description : Infertility servicesStandard (You Pay)Basic (You Pay)

Diagnosis and treatment of infertility, except as shown in Plan exclusions:  

  • Infertility services are covered for Artificial Insemination up to 6 cycles
  • In Vitro Fertilization with up to 3 cycles is covered

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

30% of charges / $9000 maximum

50% of charges / $9000 maximum

Plan exclusions:

 - Infertility services after voluntary sterilization 

 - Fertility drugs for procedures excluded under this contract

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

  • Artificial insemination (except as noted above) (AI)
  • In vitro fertilization (except as noted above) (IVF)
  • Embryo transfer and gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)
  • Services and supplies related to ART procedures

 - Cost of donor sperm

 -  Cost of donor egg

All charges

All charges

Benefit Description : Allergy careStandard (You Pay)Basic (You Pay)
  • 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

All charges

Benefit Description : Treatment therapiesStandard (You Pay)Basic (You Pay)
  • 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)
Note: We only cover GHT when we preauthorize the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary. See Other services under You need prior Plan approval for certain services on page 18.

$50 per visit to a specialist

$50 per visit to a specialist

Benefit Description : Physical, occupational, and speech therapies Standard (You Pay)Basic (You Pay)

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

Benefit Description : Habilitative TherapyStandard (You Pay)Basic (You Pay)
Habilitative services for children under age 19 with congenital or genetic birth defects including, but not limited to, autism or an autism spectrum disorder, and cerebral palsy. Services included physical, occupational and speech therapy for 60 visits per year, per service.

$50 per visit to a specialist

$50 per visit to a specialist

Benefit Description : Hearing services (testing, treatment, and supplies)Standard (You Pay)Basic (You Pay)
  • 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

Benefit Description : Vision services (testing, treatment, and supplies)Standard (You Pay)Basic (You Pay)
  • 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

Benefit Description : Foot care Standard (You Pay)Basic (You Pay)

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

Benefit Description : Orthopedic and prosthetic devices Standard (You Pay)Basic (You Pay)

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

Benefit Description : Durable medical equipment (DME)Standard (You Pay)Basic (You Pay)

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

All charges

Benefit Description : Home health servicesStandard (You Pay)Basic (You Pay)
  • 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

Benefit Description : Chiropractic Standard (You Pay)Basic (You Pay)
  • 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

Benefit Description : Alternative treatmentsStandard (You Pay)Basic (You Pay)

"No benefit"

All charges

All charges

Benefit Description : Educational classes and programsStandard (You Pay)Basic (You Pay)

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
  • Childhood obesity education

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 (Balance, Nourish, Relax, Breathe, Care for Depression, Dream, Care for Your Health, Care for Pain)

No cost for participating in wellness programs.

No cost for participating in wellness programs.




Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other HealthCare Professionals (Standard and Basic Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • For the Standard Option, the calendar year deductible is $300 for Self Only, $600 for Self Plus One or $600 for Self and Family. For the Basic Option, the calendar year deductible is $1,500 for Self Only, $3,000 for Self Plus One or $3,000 for Self and Family. The calendar year deductible is applied to almost all benefits in this Section.  We added “(deductible applies)” to show when the calendar year deductible does apply.
  • Plan physicians must provide or arrange your care.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • The services listed below are for the charges billed by a physician or other healthcare professional for your surgical care. See Section 5(c) for charges associated with a facility (i.e. hospital, surgical center, etc.).
  • YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.



Benefit Description : Surgical proceduresStandard (You Pay)Basic (You Pay)

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 morbid 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
Note:  We pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.

 (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

Benefit Description : Reconstructive surgery Standard (You Pay)Basic (You Pay)
  • 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.
  • Surgical treatment for gender reassignment is limited to the following:
    • Mastectomy
    • Urethroplasty (reconstruction of female urethra)
    • Amputation of penis
    • Penile prosthesis
    • Orchiectomy
    • Insertion of testicular prosthesis
    • Scrotoplasty
    • Intersex surgery male to female [a series of staged procedures]
    • Intersex surgery female to male [a series of staged procedures]
    • Vulvectomy
    • Plastic repair of introitus
    • Clitoroplasty for intersex state
    • Perineoplasty
    • Vaginectomy
    • Construction of artificial vagina
    • Vaginoplasty for intersex state
    • Hysterectomy
    • Salpingo-oophorectomy
  • 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.

(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

Benefit Description : Oral and maxillofacial surgeryStandard (You Pay)Basic (You Pay)

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.

(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

Benefit Description : Organ/tissue transplantsStandard (You Pay)Basic (You Pay)

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 

 (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)

 (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)

    - 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

(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

 (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.

 (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

Benefit Description : AnesthesiaStandard (You Pay)Basic (You Pay)

Professional services provided in –

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

(deductible applies)

20% coinsurance (deductible applies)




Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services (Standard and Basic Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
  • For the Standard Option, the calendar year deductible is $300 for Self Only, $600 for Self Plus One or $600 for Self and Family. For the Basic Option, the calendar year deductible is $1,500 for Self Only, $3,000 for Self Plus One or $3,000 for Self and Family. The calendar year deductible is applied to almost all benefits in this Section.  We added “(deductible applies)” to show when the calendar year deductible does apply.
  • Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge (i.e., physicians, etc.) are in Sections 5(a) or (b).
  • YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.



Benefit Description : Inpatient hospitalStandard (You Pay)Basic (You Pay)

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

Benefit Description : Outpatient hospital or ambulatory surgical centerStandard (You Pay)Basic (You Pay)
  • 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
Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

10% coinsurance (deductible applies)

20% coinsurance (deductible applies)

Benefit Description : Extended care benefits/Skilled nursing care facility benefitsStandard (You Pay)Basic (You Pay)
  • 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

Benefit Description : Hospice careStandard (You Pay)Basic (You Pay)

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

Nothing

Plan exclusions: Independent nursing, homemaker services.

All charges

All charges

Benefit Description : AmbulanceStandard (You Pay)Basic (You Pay)
  • Local professional ambulance service when medically appropriate

$125 per trip (deductible applies)

20% coinsurance (deductible applies)




Section 5(d). Emergency Services/Accidents (Standard and Basic Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • For the Standard Option, the calendar year deductible is $300 for Self Only, $600 for Self Plus One or $600 for Self and Family. For the Basic Option, the calendar year deductible is $1,500 for Self Only, $3,000 for Self Plus One or $3,000 for Self and Family. The calendar year deductible is applied to almost all benefits in this Section.  We added “(deductible applies)” to show when the calendar year deductible does apply.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.



What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need for quick action.


What to do in case of emergency:

Emergencies within our service area

If you have symptoms of heart attack or stroke or feel that your "life or limb" is in danger, go immediately to the emergency room or call 911. If you have any of the following, go to the emergency room or call 911:

  • Chest pain or pressure
  • Uncontrolled bleeding
  • Sudden or severe pain
  • Coughing or vomiting blood
  • Difficulty breathing or shortness of breath
  • Sudden dizziness, weakness, or changes in vision
  • Severe or persistent vomiting or diarrhea
  • Changes in mental status, such as confusion

Emergencies outside our service area 

In all emergency situations, you are encouraged to seek care with the nearest BSWHP approved provider; however, if the time needed to reach an BSWHP approved provider might endanger your health, go to the nearest emergency room. Medically necessary emergency care is covered. If you are hospitalized as a result of the emergency, you should contact the BSWHP Health Services Department within 24-48 hours of any admission at 888-316-7947.




Benefit Description : Emergency within our service areaStandard (You pay)Basic (You pay)
  • 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

All charges

Benefit Description : Emergency outside our service areaStandard (You pay)Basic (You pay)
  • 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

All charges

Benefit Description : AmbulanceStandard (You pay)Basic (You pay)

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




Section 5(e). Mental Health and Substance Use Disorder Benefits (Standard and Basic Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • For the Standard Option, the calendar year deductible is $300 for Self Only, $600 for Self Plus One or $600 for Self and Family. For the Basic Option, the calendar year deductible is $1,500 for Self Only, $3,000 for Self Plus One or $3,000 for Self and Family. The calendar year deductible is applied to almost all benefits in this Section.  We added “(deductible applies)” to show when the calendar year deductible does apply.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • We will provide medical review criteria or reasons for treatment plan denials to enrollees, members or providers upon request or as otherwise required.
  • OPM will base its review of disputes about treatment plans on the treatment plan’s clinical appropriateness.  OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.



Benefit Description : Professional servicesStandard (You Pay)Basic (You Pay)

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.

  • Physician services

$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

Benefit Description : Inpatient hospital or other covered facilityStandard (You Pay)Basic (You Pay)

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)

Benefit Description : Outpatient hospital or other covered facilityStandard (You Pay)Basic (You Pay)

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

$25 per visit

$25 per visit




TermDefinition

Precertification

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.




See these sections of the brochure for more valuable information about these benefits:

  • Section 4, Your cost for covered services, for information about catastrophic protection for these benefits.
  • Section 7, Filing a claim for covered services, for information about submitting out-of-network claims.



Section 5(f). Prescription Drug Benefits (Standard and Basic Option)

Important things you should keep in mind about these benefits:

  • We cover prescribed drugs and medications, as described in the chart beginning on the next page.
  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Members must make sure their prescribers obtain prior approval/authorizations for certain prescription drugs and supplies before coverage applies. Prior approval/authorizations must be renewed periodically.
  • Federal law prevents the pharmacy from accepting unused medications. 
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.

We cover prescribed drugs and medications, as described in the chart beginning on the next page.




There are important features you should be aware of. These include:

  • Who can write your prescription. A licensed physician or dentist, and in states allowing it, licensed/or certified providers with prescriptive authority prescribing within their scope of practice must prescribe your medication.
  • Where you can obtain them. BSWHP has a network of pharmacies available within Central, North and West Texas and the BSWHP Provider Area to accommodate the needs of our members. BSW also owns and operates its own mail order facility.  BSWHP also contracts with most major retail pharmacies for those members where an BSW pharmacy is not located.   
  • Mail Order Prescription Drugs  Mail order is both available through BSW and Optum or by call by calling the pharmacy at 855-388-3090 (BSWHP) or 855-205-9182 (OptumRx).  Mail order is provided by the Baylor Scott & White or OptumRx.
  • We use a formulary. BSWHP uses a standard formulary called the Group Value Formulary which is a list of medications that are both medically appropriate and cost-effective. All drugs have been reviewed and approved by a team of health care providers including doctors and pharmacists to be included on our formulary. If your drug is not listed on the formulary, you can talk with your doctor about switching to a formulary drug that may be lower in cost and as effective. If you need to continue using the drug not listed and the drug is not excluded, you or your physician may submit a request for coverage based on medical necessity. If approved you’ll pay the applicable copayment or coinsurance. If not approved and you still want to take it, you’ll pay the full cost. Please visit https://fehb.swhp.org for the formulary list of drugs.
  • These are the dispensing limitations. There may be limitations on drugs that require prior authorization. “Prior Authorization Required” drugs are usually those that have multiple uses, have a high potential for waste, or require close monitoring by the physician. A generic equivalent will be dispensed if it is available unless your physician specifically requires a name brand.  If a brand-name medication is dispensed when a generic equivalent is available, prior authorization is required for coverage. If approved, the relevant Non-Preferred copay applies. These are the dispensing limitations:
      • Prior Authorization: BSWHP requires you or your physician to get prior authorization before filling certain drugs. Drugs needing prior authorization are noted on the formulary by a “PA” next to the drug name.
      • Step Therapy: In some cases, BSWHP requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. Drugs with step therapy are noted on the formulary by an “ST” next to the drug name.
      • Drug Exception: A medication may require a drug exception for a variety of reasons, i.e.; may be limited to certain Specialty prescribers, limited to certain pharmacies, may be a medication that is part of the therapeutic interchange programs, or various other reasons. Please contact our customer service department for questions regarding these medications. 
      • Quantity Limit: For certain drugs, BSWHP limits the amount of medication covered. Quantity limits help ensure the appropriate use of medications. Quantity limits are often applied for safety reasons (e.g. limiting products containing acetaminophen to maximum safe limits). Drugs with quantity limits are noted on the formulary by a “QL” next to the drug name.
      • Age Restriction: There are certain medications which may be limited to a certain age group. Drugs with age restrictions are noted on the formulary by an “AL” next to the drug name.
  • A generic equivalent will be dispensed if it is available by your pharmacist. If you or your physician request brand name, prior authorization will be required for coverage.
  • Why use generic drugs? As a rule, generic drugs are about 30 to 80 percent less expensive than brand name drugs. When a drug goes off patent, other companies can apply for approval to sell the drug as a generic. The generic is chemically the same as the brand name drug. Because there is competition among the generic manufacturers, the cost is typically much lower.
  • When you have to claim to file?  You will need to file a claim for reimbursement directly to OptumRx Claims Department, PO Box 650334, Dallas, TX, 75265-0334



Benefits Description : Covered medications and suppliesStandard (You Pay)Basic (You Pay)

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

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

  • $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)
  • $150 (Preferred Brand) Maintenance (90-day supply)
  • $375 (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)

Refer to the list of Women's contraception drugs and devices that are covered at $0 copay at: https://fehb.swhp.org/pharmacy-information.

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
  • A prescription that has an over the counter alternative
Note: Over-the-counter and prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation program benefit. See page (Applies to printed brochure only).

All charges

All charges




Section 5(g). Dental Benefits (Standard and Basic Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your FEHB Plan will be the First/Primary payor of any Benefit payments and your FEDVIP Plan is secondary to your FEHB Plan. See Section 9 Coordinating benefits with other coverage.
  • Plan dentists must provide or arrange your care.
  • For the Standard Option, the calendar year deductible is $300 for Self Only, $600 for Self Plus One or $600 for Self and Family. For the Basic Option, the calendar year deductible is $1,500 for Self Only, $3,000 for $3,000 for Self Plus One or $3,000 for Self and Family. The calendar year deductible is applied to almost all benefits in this Section.  We added “(deductible applies)” to show when the calendar year deductible does apply.
  • We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. See Section 5(c) for inpatient hospital benefits. We do not cover the dental procedure unless it is described below.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.



Accidental injury benefit : Accidental injury benefitStandard (You Pay)Basic (You Pay)

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

Accidental injury benefit : Dental benefitsStandard (You Pay)Basic (You Pay)

Plan exclusions: Routine/Restorative

All charges

All charges




Section 5(h). Wellness and Other Special Features (Standard and Basic Option)

TermDefinition

Flexible benefits option

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).

24 hour nurse line

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.

Services for deaf and hearing impaired

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

Appointment Advocates 

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.

Language Line

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.

Additional services

We also offer other valuable services to our members 24/7 including:

Standard Option:

  • Health Coaches - 888-360-1555 - call anytime you need information on a health issue
  • Dialog Center - https://fehb.swhp.org - includes shared decision making, e-mail a health coach, interactive tools
  • BSWHP Member Portal - https://fehb.swhp.org - check on your claims and benefits

Basic Option:




Non-FEHB benefits available to Plan members

The discounts on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket maximums. For more information, please call 800-290-0523 or visit https://fehb.swhp.org.

Careington POS Dental Network

  • Save 20% to 50% on most dental procedures including routine oral exams, unlimited cleanings and major work such as dentures, root canals, and crowns.
  • 20% savings on orthodontics including braces and retainers for children and adults
  • 20% reduction on specialists’ normal fees. Specialties include: Endodontics, Oral Surgery, Pediatric Dentistry, Periodontics and Prosthodontics where available.
  • Cosmetic dentistry such as bonding and veneers also included.
  • All dentists must meet highly selective credentialing standards based on education, background, license standing, and other requirements.

ChooseHealthy - Plus Fitness

 The ChooseHealthy® program provides members with access a wide variety of specialty health and wellness services. With this wellness program, members can:

  • Save 25% on services from specialty health care providers.
  • The ChooseHealthy program's full musculoskeletal provider network features more than 70,000 participating providers nationwide.
  • Choose from more than 10,000 participating fitness centers with the Active&Fit Direct™ program for $25 a month (plus a $25 enrollment fee and applicable taxes). Once enrolled, members also have access to tools to help them get the most out of their fitness membership, such as tools that allow them to track excercise.
  • Save 5% to 55% on variety popular health and fitness products.  Discounted member pricing can be viewed after registering and logging in.  Most orders offer free shipping and handling.

Please note that the ChooseHealthy program in not insurance.  You should check any insurance benefits you have before using this discount program, as those benefits may result in lower costs to you than using this discount program.  The ChooseHealthy program provides for discounts from specialty health care providers.  You are obligated to pay for all services from those providers but will receive a discount from those participating providers for services included in the program.  The ChooseHealthy program also includes the Active&Fit Direct program, which provides discounted access to fitness centers.  The ChooseHealthly program does not make any payments directly to participating providers or to the Active&Fit Direct program.  The ChooseHealthy program has no liability for providing or guaranteeing services and assumes no liability for quality of services rendered.  Discounts on product and services available through the ChooseHealthy program are subject to change; please consult the website for current availability.  

The Programs described above are provided by ChooseHealthy, Inc. and American Specialty Health Fitness, Inc., subsidiaries of American Specialty Health Incorporated (ASH).  ChooseHealthy, Active&Fit and Active&Fit Direct are trademarks of ASH and used with permission herein.  Other names and logos may be trademarks of their respective owners

EPIC Hearing Healthcare-Hearing

  • Careington members have access to hearing aid discounts from 30% to 60% at over 5,500 network providers nationwide.  The latest in hearing aid technology by name brand manufacturers is available.
  • Satisfaction guarantee:  Members have a 45-day, no-obligation trial period on products purchased.  If not completely satisfied, the member's money will be refunded (less applicable professional service fees).  
  • Members can unlock additional wellness reward savings and learn more about hearing loss through EPIC's online Listen Hear, Live Well hearing wellness program.




Section 6. General Exclusions – Things We Don’t Cover

The exclusions in this section apply to all benefits. There may be other exclusions and limitations listed in Section 5 of this brochure. Although we may list a specific service as a benefit, we will not cover it unless it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition. For information on obtaining prior approval for specific services, such as transplants, see Section 3 When you need prior Plan approval for certain services. We do not cover the following:

• Care by non-Plan providers except for authorized referrals or emergencies (see Emergency services/accidents).

• Services, drugs, or supplies you receive while you are not enrolled in this Plan.

• Services, drugs, or supplies not medically necessary.

  • Services or supplies we are prohibited from covering under the Federal Law.

• Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice.

• Experimental or investigational procedures, treatments, drugs or devices (see specifics regarding transplants).

• Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest.

• Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.

• Services, drugs, or supplies you receive without charge while in active military service.




Section 7. Filing a Claim for Covered Services

This Section primarily deals with post-service claims (claims for services, drugs or supplies you have already received). See Section 3 for information on pre-service claims procedures (services, drugs or supplies requiring prior Plan approval), including urgent care claims procedures. When you see Plan providers, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment or coinsurance. This Section primarily deals with post-service claims (claims for services, drugs or supplies you have already received). See Section 3 for information on pre-service claims procedures (services, drugs or supplies requiring prior Plan approval), including urgent care claims procedures. When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment or coinsurance.

You will only need to file a claim when you receive emergency services from non-Plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is the process:




TermDefinition

Medical and hospital benefits

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://fehb.swhp.org.

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

Prescription drugs

Submit your claims to:

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

Other supplies or services

Submit your claims to:

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

Deadline for filing your claim

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.

Post-service claims procedures

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.

Authorized Representative

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.

Notice Requirements

If you live in a county where at least 10 percent 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.




Section 8. The Disputed Claims Process

You may be able to appeal directly to the Office of Personnel Management (OPM) if we do not follow the required claims processes. For more information or to make an inquiry about situations in which you are entitled to immediately appeal to OPM, including additional requirements not listed in Sections 3, 7 and 8 of this brochure, please call your plan's customer service representative at the phone number found on your enrollment card, plan brochure, or plan website.

Please follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your post-service claim (a claim where services, drugs or supplies have already been provided). In Section 3 If you disagree with our pre-service claim decision, we describe the process you need to follow if you have a claim for services, referrals, drugs or supplies that must have prior Plan approval, such as inpatient hospital admissions.

To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan documents under our control relating to your claim, including those that involve any expert review(s) of your claim. To make your request, please contact our Customer Service Department by writing to:

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

or calling (844) 633-5325.

Our reconsideration will take into account all comments, documents, records, and other information submitted by you relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.

When our initial decision is based (in whole or in part) on a medical judgment (i.e., medical necessity, experimental/investigational), we will consult with a healthcare professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who was not involved in making the initial decision.

Our reconsideration decision will not afford deference to the initial decision and will not be conducted by a plan representative who is neither the individual who made the initial decision that is the subject of the reconsideration or their subordinate of that individual.

We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support the denial of benefits.




StepDescription

1

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 and 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.

2

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.

3

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.

4

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 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.




Note: If you have a serious or life-threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at 844-633-5325. We will expedite our review (if we have not yet responded to your claim), or we will inform OPM so they can quickly review your claim on appeal. You may call OPM’s Health Insurance 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time.

Please remember that we do not make decisions about plan eligibility issues. For example, we do not determine whether you or a dependent is covered under this plan. You must raise eligibility issues with your Agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant or the Office of Workers’ Compensation Programs if you are receiving Workers’ Compensation benefits.




Section 9. Coordinating Benefits with Other Coverage

TermDefinition

When you have other health coverage

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://fehb.swhp.org.

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 pays, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance.

TRICARE and CHAMPVA

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 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.

Workers' Compensation

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 proceedings that is based on a claim you filed under OWCP or similar laws.

Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care.

Medicaid

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 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.

When other Government agencies are responsible for your care

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

When others are responsible for injuries

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.

When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) coverage

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, 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.

Clinical trials

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.

When you have Medicare

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 (Part A or Part B)

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://fehb.swhp.org.

We waive all costs if the Original Medicare Plan is your primary payor-

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

Please review the following table it illustrates 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: $0.00

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 Physician
Standard Option You Pay Without Medicare: $25
Standard Option You Pay With Medicare Part B: $0.00

Benefit Description: Specialist
Standard Option You Pay Without Medicare: $50
Standard Option You Pay With Medicare Part B: $0.00

Benefit Description: Inpatient Hospital
Standard Option You Pay Without Medicare: $300 per day/ $1,500 copay max per admit
Standard Option You Pay With Medicare Part B: $0.00

Benefit Description: Outpatient Hospital
Standard Option You Pay Without Medicare: $250 per visit/ procedure
Standard Option You Pay With Medicare Part B: $0.00

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: $0.00

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: $0.00

Benefit Description: Specialist
Basic Option You Pay Without Medicare: $50
Basic Option You Pay With Medicare Part B: $0.00

Benefit Description: Inpatient Hospital
Basic Option You Pay Without Medicare: 20% Coinsurance
Basic Option You Pay With Medicare Part B: $0.00

Benefit Description: Outpatient Hospital
Basic Option You Pay Without Medicare: 20% Coinsurance
Basic Option You Pay With Medicare Part B: $0.00

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



Tell us about your Medicare coverage

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.

Medicare Advantage (Part C)

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 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.

Medicare prescription drug coverage (Part D)

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.




Primary Payor Chart

A. When you – or your covered spouse are age 65 or over and have Medicare and you...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have FEHB coverage on your own as an active employee
2) Have FEHB coverage on your own as an annuitant or through your spouse who is an annuitant
3) Have FEHB through your spouse who is an active employee
4) Are a reemployed annuitant with the Federal government and your position is excluded from the FEHB (your employing office will know if this is the case) and you are not covered under FEHB through your spouse under #3 above
5) Are a reemployed annuitant with the Federal government and your position is not excluded from the FEHB (your employing office will know if this is the case) and...
  • 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
6) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge) and you are not covered under FEHB through your spouse under #3 above
7) Are enrolled in Part B only, regardless of your employment status ✓ for Part B services ✓ for other services
8) Are a Federal employee receiving Workers' Compensation ✓ *
9) Are a Federal employee receiving disability benefits for six months or more


B. When you or a covered family member...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have Medicare solely based on end stage renal disease (ESRD) and..
  • 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
2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and...
  • 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
3) Have Temporary Continuation of Coverage(TCC) and...
  • 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)


C. When either you or a covered family member are eligible for Medicare solely due to disability and you...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have FEHB coverage on your own as an active employee or through a family member who is an active employee
2) Have FEHB coverage on your own as an annuitant or through a family member who is an annuitant
D. When you are covered under the FEHB Spouse Equity provision as a former spouse

*Workers' Compensation is primary for claims related to your condition under Workers’ Compensation.




Section 10. Definitions of Terms We Use in this Brochure

TermDefinition

Calendar year

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.

Clinical trials cost categories

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.

Coinsurance

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

Copayment

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

Cost-sharing

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

Covered services

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

Custodial Care

“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.

Deductible

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

Experimental or investigational services

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

Group health coverageHealth coverage, such as FEHB, that is provided through an employer group.

Healthcare professional

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

Medical necessity

Those Health Care Services which, in the opinion of Member's Primary Care Physician 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

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.

Post-service claimsAny claims that are not pre-service claims. In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits.

Pre-service claims

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.

Reimbursement

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.

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.

Urgent care claims

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/We

Us and We refer to Baylor Scott and White Health Plan

YouYou refers to the enrollee and each covered family member.



Index

Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.



Index Entry
(Page numbers solely appear in the printed brochure)



Summary of Benefits for the Standard Option of Baylor Scott and White Health Plan - 2022

Do not rely on this chart alone. This is a summary.   All benefits are subject to the definitions, limitations, and exclusions in this brochure.  Before making a final decision, please read this FEHB brochure.  You can also obtain a copy of our Summary Of Benefits and Coverage as required by the Affordable Care Act at https://fehb.swhp.org.  

  • If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
  • We only cover services provided or arranged by Plan physicians, except in emergencies.

Below, an asterisk (*) means the item is subject to the calendar year deductible. Self Only $300, Self Plus One and Self and Family $600.




Standard Option BenefitsYou PayPage

Medical services provided by physicians:

Diagnostic and treatment services provided in the office

Office visit copay: $25 primary care; $50 specialist

27

Services provided by a hospital:

  • Inpatient

10% coinsurance*

45

Services provided by a hospital:

  • Outpatient

10% coinsurance*

46

Emergency benefits:

  • In and out-of-area

10% coinsurance*

47

Mental health and substance use disorder treatment:

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

49

Prescription drugs:

  • Retail Pharmacy Drugs (30 day supply)

  • $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

Prescription drugs:

  • Maintenance or Mail Order Prescription Drugs – (90-day supply)

  • $25 (Preferred Generic) 90-day supply
  • $150 (Preferred Brand) 90-day supply
  • $375 (Non-Preferred brand) 90-day supply

53

Dental Care: No benefit except for services related to accidental injury.

$50 outpatient

55

Vision care: Annual eye refraction

$50 specialist copay

34

Protection against catastrophic costs (out-of-pocket maximum):

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

24




Summary of Benefits for the Basic Option for Baylor Scott and White Health Plan - 2022

Do not rely on this chart alone.  This is a summary.  All benefits are  subject to the definitions, limitations, and exclusions in this brochure. You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at https://fehb.swhp.org.  

  • If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
  • We only cover services provided or arranged by Plan physicians, except in emergencies.

Below, an asterisk (*) means the item is subject to the calendar year deductible. Self Only $1,500, Self Plus One and Self Plus Family $3,000.




Basic Option BenefitsYou payPage

Medical services provided by physicians:

Diagnostic and treatment services provided in the office

Office visit copay: $25 primary care; $50 specialist

27

Services provided by a hospital:

  • Inpatient

20% coinsurance*

45

Services provided by a hospital:

  • Outpatient 

20% coinsurance*

46

Emergency benefits:

  • In and out-of-area

20% coinsurance*

47

Mental Health and substance use disorder treatment:

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

49

Prescription drugs:

  • Retail Pharmacy Drugs (30-day supply)
  • $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

Prescription drugs:

  • Maintenance or Mail Order Prescription Drugs - (90 day supply)

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

53

Dental care:  No benefit except for services related to accidental injury

$50 outpatient

55

Vision care:     Annual eye refraction

$50 specialist copay

34

Protection against catastrophic costs

(out-of-pocket maximium):

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

24




2022 Rate Information for Baylor Scott and White Health Plan

To compare your FEHB health plan options please go to www.opm.gov/fehbcompare.

To review premium rates for all FEHB health plan options please go to www.opm.gov/FEHBpremiums or www.opm.gov/Tribalpremium.

Rates apply to most non-Postal employees. If you are in a special enrollment category, contact the agency that maintains your health benefits enrollment.

Postal rates apply to certain United States Postal Service employees as follows:

  • Postal Category 1 rates apply to career bargaining unit employees who are represented by the following agreement: NALC.
  • Postal Category 2 rates apply to career bargaining unit employees who are represented by the following agreement: PPOA.

Non-Postal rates apply to all career non-bargaining unit Postal Service employees and career bargaining unit employees who are represented by the following agreements:  APWU, IT/AS, NPMHU, NPPN and NRLCA. Postal rates do not apply to non-career Postal employees, Postal retirees, and associate members of any Postal employee organization who are not career Postal employees

If you are a Postal Service employee and have questions or require assistance, please contact:

USPS Human Resources Shared Service Center: 1-877-477-3273, option 5, Federal Relay Service 1-800-877-8339

Premiums for Tribal employees are shown under the monthly non-Postal column.  If the amount shown under employee contribution is the maximum you will pay.  Your Tribal employer may choose to contribute a higher portion of your premium. Please contact your Tribal Benefits Officer for exact rates.

Please see rates on the next page.

 




Central & West Texas
Type of EnrollmentEnrollment CodePremium Rate
BiWeekly
Gov't Share
Premium Rate
BiWeekly
Your Share
Premium Rate
Monthly
Gov't Share
Premium Rate
Monthly
Your Share
Standard Option Self OnlyA84$244.86$222.53$530.53$482.15
Standard Option Self Plus OneA86$524.63$512.00$1,136.70$1,109.33
Standard Option Self and FamilyA85$574.13$523.15$1,243.95$1,133.49
Basic Option Self OnlyA81$191.67$63.89$415.28$138.43
Basic Option Self Plus OneA83$424.78$141.59$920.36$306.78
Basic Option Self and FamilyA82$449.62$149.87$974.18$324.72












North Texas
Type of EnrollmentEnrollment CodePremium Rate
BiWeekly
Gov't Share
Premium Rate
BiWeekly
Your Share
Premium Rate
Monthly
Gov't Share
Premium Rate
Monthly
Your Share
Standard Option Self OnlyP84$244.86$235.68$530.53$510.64
Standard Option Self Plus OneP86$524.63$541.20$1,136.70$1,172.60
Standard Option Self and FamilyP85$574.13$554.08$1,243.95$1,200.51
Basic Option Self OnlyP81$197.57$65.85$428.06$142.68
Basic Option Self Plus OneP83$437.89$145.96$948.76$316.25
Basic Option Self and FamilyP82$463.50$154.50$1,004.25$334.75