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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 West Texas. 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. 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) plan has a $300 deductible for prescription drugs. After you meet your deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, in the initial coverage phase, you will pay a $7 copay for preferred generic drugs at a preferred pharmacy, a $14 copay at a standard pharmacy, and no copay through standard mail. For non-preferred drugs, you pay 29% coinsurance. 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 a wide range of benefits with varying cost-sharing. This plan includes coverage for inpatient and outpatient hospital services, with copays and coinsurance applying to different services. Other key benefits include coverage for primary care, preventive services, hearing, vision, dental, and home health services, each with specific copays, coinsurance, and annual limits.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both requiring prior authorization. For Inpatient Hospital-Acute, you'll pay a $325 copay for days 1-6 and a $0 copay for days 7-90, and for Inpatient Hospital Psychiatric, you'll pay a $318 copay for days 1-5 and a $0 copay for days 6-90; additional days and non-Medicare-covered stays are not covered for either.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a $350 copay and 20% coinsurance, Observation Services with 20% coinsurance, Ambulatory Surgical Center (ASC) Services with a $275 copay, Outpatient Substance Abuse Services with a $45 copay for both individual and group sessions, and Outpatient Blood Services with 20% coinsurance.
Partial Hospitalization See details
Partial Hospitalization is covered by BSW SeniorCare Advantage (PPO), with a $40 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services under the BSW SeniorCare Advantage (PPO) plan include coverage for Medicare-covered ground and air ambulance services, each with a copay of $325 and no coinsurance. Transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the BSW SeniorCare Advantage (PPO) plan. Emergency Services have a $120 copay with no coinsurance, while Urgently Needed Services have a $50 copay and no coinsurance. Worldwide Emergency Services have a maximum plan benefit coverage of $5,000.
Primary Care See details
The BSW SeniorCare Advantage (PPO) plan covers Primary Care Physician Services, Chiropractic Services, Occupational Therapy, Physician Specialist Services, Mental Health Specialty Services, Other Health Care Professional, Psychiatric Services, Physical Therapy, Speech-Language Pathology Services, Additional Telehealth Benefits and Opioid Treatment Program Services. Chiropractic services have a $15 copay, Physician Specialist Services have a $35 copay, Physical Therapy and Speech-Language Pathology Services have a $35 copay, and Occupational Therapy services have a minimum and maximum copay of $35. Mental Health and Psychiatric Services have a minimum and maximum copay of $40 for individual and group sessions. Other Health Care Professional and Opioid Treatment Program Services have a minimum and maximum copay of $45. Routine Chiropractic Care is not covered.
Preventive Services See details
The BSW SeniorCare Advantage (PPO) plan covers preventive services including Medicare-covered services with no copay, but does not cover annual physical exams. Additional services like Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), and others are not covered. Glaucoma screenings, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKGs following Welcome Visits are covered.
Hearing Services See details
Hearing Services with the BSW SeniorCare Advantage (PPO) plan includes hearing exams with a $40 copay. The plan covers prescription hearing aids up to $1,000 every three years, but does not cover Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, and Prescription Hearing Aids - Over the Ear.
Vision Services See details
BSW SeniorCare Advantage (PPO) covers vision services, including routine eye exams with a $40 copay. The plan also covers eyewear, including contact lenses (12 pairs per year), eyeglasses with lenses and frames (1 pair per year), eyeglass lenses (1 pair per year), and eyeglass frames (1 frame per year), with a combined maximum benefit of $150 per year for in-network services, but upgrades are not covered.
Dental Services See details
BSW SeniorCare Advantage (PPO) covers a maximum of $3,500 per year for dental services. This plan covers oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), and other preventive dental services. Restorative Services and Prosthodontics, fixed and removable have a coinsurance between 0% and 50%, while Adjunctive General Services, Endodontics, Periodontics, Implant Services, and Oral and Maxillofacial Surgery have a 50% coinsurance. Fluoride Treatment, Maxillofacial Prosthetics, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with coinsurance between 0% and 20%. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered by the BSW SeniorCare Advantage (PPO) plan. The plan has a coinsurance of 20% for dialysis services.
Medical Equipment See details
Medical Equipment benefits are covered, including Durable Medical Equipment (DME) with 20% coinsurance, Prosthetic Devices with 20% coinsurance, and Medical Supplies with 20% coinsurance, but Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered. There is no copay for any of these services.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by BSW SeniorCare Advantage (PPO). Diagnostic services and lab 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 and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the BSW SeniorCare Advantage (PPO) plan. While Cardiac Rehabilitation Services are listed as a covered benefit, the plan does not cover any of the listed sub-services.
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 per day; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services include Over-the-Counter (OTC) Items, with a maximum benefit of $100 every three months, including Nicotine Replacement Therapy and Naloxone; however, 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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