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BSW SeniorCare Advantage (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for BSW SeniorCare Advantage (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on BSW SeniorCare Advantage (PPO) in 2025, please refer to our full plan details page.
BSW SeniorCare Advantage (PPO) is a PPO plan offered by Baylor Scott & White Holdings available for enrollment in 2025 to people living in Dallas/Ft. Worth Metro Area. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that BSW SeniorCare Advantage (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about BSW SeniorCare Advantage (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For BSW SeniorCare Advantage (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $300.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $10000.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $10000.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The BSW SeniorCare Advantage (PPO) plan has an enhanced alternative drug benefit. The plan has a $300 deductible for prescription drugs. After the deductible, your cost will vary depending on the drug tier and pharmacy. For example, you'll pay a $7 copay at a preferred pharmacy for preferred generic drugs, or 29% coinsurance for non-preferred drugs. Once your total drug costs reach $2000, you enter the catastrophic coverage phase and pay nothing for covered drugs.
Additional Benefits
The BSW SeniorCare Advantage (PPO) plan offers comprehensive coverage, including inpatient hospital stays with a copay, outpatient services with coinsurance and copays, and emergency services with copays. The plan also includes coverage for vision and dental services, hearing exams, and medical equipment with coinsurance. Additionally, this plan provides coverage for home health services, skilled nursing facilities, and other services such as prescription hearing aids and over-the-counter items. However, certain services like annual physical exams, additional hours of care, and specialized services are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, with a copay of $320 per day for days 1-6 and no copay for days 7-90 for Inpatient Hospital-Acute, and a copay of $318 per day for days 1-5 and no copay for days 6-90 for Inpatient Hospital Psychiatric. Additional days and non-Medicare covered stays for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with a 20% coinsurance and a $350 copay for outpatient hospital services, and a 20% coinsurance for observation services. Ambulatory Surgical Center (ASC) Services have a $275 copay. Outpatient Substance Abuse Services cover individual and group sessions, each with a copay between $45 and $45. Outpatient Blood Services are covered with a 20% coinsurance.
Partial Hospitalization See details
Partial Hospitalization is covered under the BSW SeniorCare Advantage (PPO) plan, with a $40 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the BSW SeniorCare Advantage (PPO) plan. The plan has a $325 copay for both ground and air ambulance services, with no coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services have a $120 copay, while Urgently Needed Services have a $50 copay; both have no coinsurance. Worldwide Emergency Services has a maximum plan benefit coverage of $5,000.
Primary Care See details
The BSW SeniorCare Advantage (PPO) plan covers primary care physician services with no copay, chiropractic services with a $15 copay, and occupational therapy services with a $35 copay. Physician specialist services, physical therapy, and speech-language pathology services have a $35 copay, and mental health specialty services and psychiatric services have a $40 copay. Other health care professional services and opioid treatment program services each have a $45 copay, and routine chiropractic care is not covered.
Preventive Services See details
The BSW SeniorCare Advantage (PPO) plan covers preventive services including Medicare-covered services, kidney disease education services, and other preventive services like glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. However, annual physical exams and services such as health education, in-home safety assessments, and many others are not covered.
Hearing Services See details
Hearing Services includes coverage for hearing exams with a $40 copay, as well as Routine Hearing Exams and Fitting/Evaluation for Hearing Aids, each covered once per year. Prescription Hearing Aids (all types) are covered up to $1,100 every three years for in-network services, but Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, Prescription Hearing Aids - Over the Ear, and OTC Hearing Aids are not covered.
Vision Services See details
The BSW SeniorCare Advantage (PPO) plan covers vision services, including routine eye exams with a $40 copay. Eyewear is covered with a combined maximum of $150 per year for in-network services, and contact lenses, eyeglass lenses, and eyeglass frames are also covered.
Dental Services See details
Dental services are covered, with a maximum benefit of $3,500 per year for both in-network and out-of-network services. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), and other preventive dental services are covered, while fluoride treatment is not covered. Restorative services have a coinsurance between 0% and 50%, adjunctive general services, endodontics, periodontics, implants, and oral and maxillofacial surgery have a 50% coinsurance, and prosthodontics (removable and fixed) have a coinsurance between 0% and 50%. Orthodontic services are covered under Diagnostic and Preventive Dental.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the BSW SeniorCare Advantage (PPO) plan. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the BSW SeniorCare Advantage (PPO) plan. The coinsurance for these services is 20%.
Medical Equipment See details
Medical Equipment benefits are covered under the BSW SeniorCare Advantage (PPO) plan. Durable Medical Equipment (DME) has a 20% coinsurance, while Durable Medical Equipment for use outside the home and Diabetic Supplies/Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with prior authorization required. Diagnostic procedures/tests, lab services, and outpatient X-Ray services are not covered, while diagnostic radiological services have a copay of up to $300, and therapeutic radiological services have a coinsurance of 20%.
Home Health Services See details
Home Health Services are covered by the BSW SeniorCare Advantage (PPO) plan with no copay or coinsurance, but authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the BSW SeniorCare Advantage (PPO) plan, though the specific services of Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, and Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services are not covered. There is a copay for the services that are covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the BSW SeniorCare Advantage (PPO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items, with a maximum benefit of $80 every three months, including Nicotine Replacement Therapy and Naloxone coverage. Acupuncture, Meal Benefit, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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