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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 2026, please refer to our full plan details page.
BSW SeniorCare Advantage (PPO) is a PPO plan offered by Baylor Scott & White Health available for enrollment in 2025 to people living in West Texas. This plan received an overall rating of 4 out of 5 stars in 2026.
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. Additionally, this plan comes with a Part B Premium reduction of $5.00. You must continue to pay paying your reduced 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) Medicare plan features a $300 annual prescription drug deductible. For Tier 1 preferred generic drugs, members pay no copay at preferred pharmacies and through standard mail order, or a $5 copay for a one-month supply at standard pharmacies. Tier 2 generic drugs also have no copay for standard mail order, with copays starting at $7 at preferred pharmacies. Tier 3 preferred brand drugs require a $47 copay for a one-month supply at both preferred and standard pharmacies. Higher-tier medications require coinsurance rather than flat copays, with Tier 4 non-preferred drugs requiring 35% coinsurance and Tier 5 specialty drugs requiring 29% coinsurance.
Additional Benefits
The BSW SeniorCare Advantage (PPO) plan offers comprehensive medical coverage with no copay or coinsurance for primary care, telehealth, and preventive services. Specialist visits require a $35 copay, while inpatient hospital stays carry a $325 daily copay for the first six days and no copay thereafter. Emergency care is available with a $130 copay and no coinsurance, which is waived upon hospital admission. Supplemental dental benefits feature no copay and up to a $3,500 annual limit, while routine vision and hearing exams require a $40 copay. Members also benefit from a $130 quarterly over-the-counter allowance and home health services with no copay or coinsurance. Durable medical equipment requires a 20% coinsurance, whereas diabetic equipment is covered with no copay or coinsurance.
Inpatient Hospital See details
Inpatient hospital care is partially covered by BSW SeniorCare Advantage (PPO) with no coinsurance, although prior authorization is required and upgrades, additional days, and non-Medicare-covered stays are not covered. Acute stays require a $325 copay for days 1 through 6 and no copay for days 7 through 90, while psychiatric stays require a $318 copay for days 1 through 5 and no copay for days 6 through 90.
Outpatient Services See details
BSW SeniorCare Advantage (PPO) covers outpatient hospital services with a $350 copay and 20% coinsurance, and ambulatory surgical center services with a $275 copay and no coinsurance. Additionally, outpatient substance abuse services require a $45 copay and no coinsurance, while outpatient blood services feature no copay and a 20% coinsurance.
Partial Hospitalization See details
BSW SeniorCare Advantage (PPO) covers partial hospitalization services with a $40 copay and no coinsurance. Prior authorization may be required depending on the specific services received.
Ambulance and Transportation Services See details
BSW SeniorCare Advantage (PPO) covers ground and air ambulance services with a $325 copay and no coinsurance. While some transportation services are covered, transportation to plan-approved health-related locations and any other health-related locations is not covered.
Emergency Services See details
BSW SeniorCare Advantage (PPO) covers emergency services with a $130 copay and no coinsurance, and urgently needed services with a $50 copay and no coinsurance, with both copays waived if admitted to the hospital within 24 hours. Worldwide emergency, urgent, and transportation services are also covered with no copay or coinsurance, up to a maximum plan benefit of $5,000.
Primary Care See details
BSW SeniorCare Advantage (PPO) provides primary care physician services and telehealth benefits with no copay and no coinsurance, while specialist visits, physical therapy, and occupational therapy require a $35 copay and no coinsurance. Mental health, psychiatric, and opioid treatment services have copays ranging from $40 to $45 with no coinsurance, though podiatry and chiropractic services are not covered.
Preventive Services See details
Preventive services under the BSW SeniorCare Advantage (PPO) are covered with no copay and no coinsurance, including annual physical exams, kidney disease education, and diabetes self-management training. Additional preventive services are partially covered with no copay and no coinsurance for physical and memory fitness benefits, but do not cover health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, tobacco cessation, disease management, telemonitoring, remote access, safety devices, and counseling.
Hearing Services See details
BSW SeniorCare Advantage (PPO) covers routine hearing exams and evaluations for a $40 copay and no coinsurance. Prescription and OTC hearing aids are covered with no copay and no coinsurance up to a $1,000 maximum every three years, though inner ear, outer ear, and over-the-ear prescription hearing aids are not covered.
Vision Services See details
BSW SeniorCare Advantage (PPO) covers routine eye exams with a $40 copay, no coinsurance, and no deductible, though other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible up to a $150 annual maximum, but upgrades are not covered.
Dental Services See details
BSW SeniorCare Advantage (PPO) partially covers dental services up to an annual maximum of $3,500 for both in-network and out-of-network care. Covered preventive and diagnostic services have no copay and no coinsurance, while comprehensive services have no copay and coinsurance ranging from no coinsurance to 50% coinsurance; fluoride treatments, maxillofacial prosthetics, and orthodontics are not covered.
Home Infusion bundled Services See details
BSW SeniorCare Advantage (PPO) covers home infusion bundled services with no copay and no coinsurance, though prior authorization is required. Covered Medicare Part B chemotherapy, radiation, and other Part B drugs carry no copay and 0% to 20% coinsurance, while Part B insulin is available for a $35 copay and no coinsurance.
Dialysis Services See details
BSW SeniorCare Advantage (PPO) covers dialysis services with no copay and a 20% coinsurance.
Medical Equipment See details
BSW SeniorCare Advantage (PPO) covers medical equipment with no copay, requiring a 20% coinsurance for durable medical equipment, prosthetics, and medical supplies. Diabetic equipment is covered with no copay and no coinsurance, but diabetic supplies and therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
BSW SeniorCare Advantage (PPO) partially covers diagnostic and radiological services with prior authorization required. Some diagnostic services are covered with no copay and no coinsurance, but diagnostic procedures, tests, and lab services are not covered. Diagnostic radiological services have no copay and no coinsurance, while therapeutic radiological services require a copay and a minimum 20% coinsurance, and outpatient X-ray services are not covered.
Home Health Services See details
BSW SeniorCare Advantage (PPO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
BSW SeniorCare Advantage (PPO) offers Cardiac Rehabilitation Services with no coinsurance, though only some services are covered. Specifically, standard cardiac rehabilitation (with a $20 copay), intensive cardiac rehabilitation (with a $20 copay), pulmonary rehabilitation (with a $15 copay), and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
BSW SeniorCare Advantage (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, offering no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and additional days beyond Medicare-covered days are not covered.
Other Services See details
BSW SeniorCare Advantage (PPO) partially covers other services, offering over-the-counter (OTC) items with no copay and no coinsurance up to a maximum limit of $130 every three months. Acupuncture, meal benefits, and nicotine replacement therapy are not covered under this benefit.
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