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Baylor Scott & White Holdings

Plan ID: H2032-4-0

BSW SeniorCare Advantage (PPO)

2025 BSW SeniorCare Advantage (PPO) H2032 — 004 — 0 is a Medicare Advantage plan with drug coverage. It has received a 3.5-out-of-5 star rating from CMS for 2025.

Learn more about BSW SeniorCare Advantage (PPO) H2032 - 004 - 0, including the health and drug services it covers, by reading our easy-to-use guide. Or contact a licensed insurance agent for help now.

3.5 / 5 stars for 2025

$0.00 /mo

Monthly premium

$300.00

Drug deductible

$6400.00

Out-of-pocket maximum

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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week!

Overview Benefits & Costs Drug Coverage Additional Benefits

Plan Overview

2025 BSW SeniorCare Advantage (PPO) H2032 — 004 — 0 is a PPO offered in West Texas by Baylor Scott & White Holdings. It has a monthly premium of $0.00.

Premium Breakdown

Standard Part B Premium

$185.00

Part B premium reduction

- $0

Monthly Plan Premium

$0.00

Total Premium:

$185.00

Note:

The standard Medicare Part B premium for 2025 is $185.00. Your premium may differ based on factors like late enrollment, income (IRMAA), or disability status. Most people enrolled in Medicare Part B are required to pay this premium.

Special needs plan type

Out-of-pocket maximum

$6400.00

Plan Organization:

Baylor Scott & White Holdings

Plan Type:

PPO

Location:

West Texas

Drugs Covered:

Yes

Drug Formulary:

Formulary Link

Pharmacies:

Pharmacies Link

Doctor Choice:

Doctors Link:

Doctors Link

Deductibles

The amount you must pay each year before your plan starts to pay for covered services or drugs.

Drug deductible

$300

Note:

This plan does not charge an annual deductible for all drugs. The $300.00 annual deductible only applies to drugs in certain tiers.

Sign up for BSW SeniorCare Advantage (PPO)

Enroll online

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Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week

Drug Coverage

BSW SeniorCare Advantage (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Benefit Type

Enhanced Alternative

Prescription drug deductible

$300.00

Part D Premium Reduction

This plan's premium may be reduced for you if you qualify for the low-income subsidy (also known as LIS or "Extra help"). The following is what you'll pay for with LIS.

Part D	LIS Full
$0.00	$0.00

Initial Coverage Phase

After you pay your $300.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2000.00. Once you reach that amount, you will enter the next coverage phase.

30 Days

60 Days

90 Days

Tier	Preferred Pharmacy	Standard Pharmacy	Preferred Mail	Standard Mail
1. Preferred Generic	-	$5.00 Copay	-	-
2. Standard Generic	-	-	-	-
3. Preferred Brand	-	-	-	-
4. Non-Preferred Drug	-	-	-	-
5. Specialty Tier	-	-	-	-

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.

Additional Benefits

BSW SeniorCare Advantage (PPO) also provides the following benefits.

Note:

Limits, Authorizations, and Referrals may apply for the benefits below. Contact the plan for details.

Comprehensive dental

Adjunctive General Services

In-Network: 50 Coins - No Co pay

Out-Of-Network: 0-50% Coins - No Copay

Endodontics

In-Network: 50 Coins - No Co pay

Out-Of-Network: 0-50% Coins - No Copay

Implant Services

In-Network: 50 Coins - No Co pay

Out-Of-Network: 0-50% Coins - No Copay

Oral and Maxillofacial Surgery

In-Network: 50 Coins - No Co pay

Out-Of-Network: 0-50% Coins - No Copay

Periodontics

In-Network: 50 Coins - No Co pay

Out-Of-Network: 0-50% Coins - No Copay

Prosthodontics, fixed

In-Network: 0-50 Coins - No Co pay

Out-Of-Network: 0-50% Coins - No Copay

Prosthodontics, removable

In-Network: 0-50 Coins - No Co pay

Out-Of-Network: 0-50% Coins - No Copay

Restorative Services

In-Network: 0-50 Coins - No Co pay

Out-Of-Network: 0-50% Coins - No Copay

Preventive dental

Dental X-Rays

In-Network: No Coins - No Copay

Out-Of-Network: 0-50% Coins - No Copay

Oral Exams

In-Network: No Coins - No Copay

Out-Of-Network: 0-50% Coins - No Copay

Other Diagnostic Dental Services

In-Network: No Coins - No Copay

Out-Of-Network: 0-50% Coins - No Copay

Other Preventive Dental Services

In-Network: No Coins - No Copay

Out-Of-Network: 0-50% Coins - No Copay

Prophylaxis (cleaning)

In-Network: No Coins - No Copay

Out-Of-Network: 0-50% Coins - No Copay

Diagnostic procedures/lab services/imaging

Diagnostic radiology services

Outpatient x-rays

In-Network: $0 copay

Out-Of-Network: 35% coinsurance

Diagnostic tests and procedures

In-Network: $0 copay

Out-Of-Network: 35% coinsurance

Lab services

In-Network: $0 copay

Out-Of-Network: 35% coinsurance

Doctor visits

Primary

In-Network: $0 copay

Out-Of-Network: 35% coinsurance per visit

Specialist

In-Network: $35 copay per visit

Out-Of-Network: 35% coinsurance per visit

Emergency care/Urgent care

Emergency

$120 copay per visit (always covered)

Urgent care

$50 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment

In-Network: $45 copay

Out-Of-Network: 35% coinsurance

Routine foot care

Not covered

Ground ambulance

All service types

In-Network: $325 copay

Out-Of-Network: 35% coinsurance

Hearing

Medicare-Covered Hearing Exam

In-Network: $40 copay

Out-Of-Network: 35% coinsurance

Fitting/evaluation

In-Network: $0 copay

Out-Of-Network: 35% coinsurance

Hearing aids

In-Network: $0 copay

Out-Of-Network: 35% coinsurance

Hearing aids OTC

Not covered

Inpatient hospital coverage

All service types

In-Network: $325 per day for days 1 through 6 $0 per day for days 7 through 90

Out-Of-Network: 35% per day for days 1 through 6 35% per day for days 7 through 90

Outpatient hospital coverage

All service types

In-Network: $350 copay or 20% coinsurance per visit

Out-Of-Network: 35% coinsurance per visit

Optional benefits

All service types

Medical equipment/supplies

Durable medical equipment

Prosthetics

Diabetes supplies

In-Network: $0 copay

Out-Of-Network: 35% coinsurance per item

Medicare Part B drugs

Chemotherapy

In-Network: 0-20% coinsurance

Out-Of-Network: 35% coinsurance

Other Part B drugs

In-Network: 0-20% coinsurance

Out-Of-Network: 35% coinsurance

Mental health services

Outpatient group therapy visit

In-Network: $40 copay

Out-Of-Network: 35% coinsurance

Outpatient individual therapy visit

In-Network: $40 copay

Out-Of-Network: 35% coinsurance

Outpatient individual therapy visit with a psychiatrist

In-Network: $40 copay

Out-Of-Network: 35% coinsurance

Outpatient group therapy visit with a psychiatrist

In-Network: $40 copay

Out-Of-Network: 35% coinsurance

Inpatient hospital - psychiatric

In-Network: $318 per day for days 1 through 5 $0 per day for days 6 through 90

Out-Of-Network: 35% per day for days 1 through 5 35% per day for days 6 through 90

Preventive care

All service types

In-Network: $0 copay

Out-Of-Network: 35% coinsurance

Rehabilitation services

Occupational therapy visit

In-Network: $35 copay

Out-Of-Network: 35% coinsurance

Physical therapy and speech and language therapy visit

In-Network: $35 copay

Out-Of-Network: 35% coinsurance

Skilled Nursing Facility

All service types

In-Network: $0 per day for days 1 through 20 $214 per day for days 21 through 100

Out-Of-Network: 35% per stay 35% per day for days 1 through 20 35% per day for days 21 through 100

Transportation

All service types

Not covered

Vision

Eyeglass frames

In-Network: $0 copay

Out-Of-Network: 35% coinsurance

Eyeglass lenses

In-Network: $0 copay

Out-Of-Network: 35% coinsurance

Routine eye exam

In-Network: $0 copay

Out-Of-Network: 35% coinsurance

Contact lenses

In-Network: $0 copay

Out-Of-Network: 35% coinsurance

Eyeglasses (frames and lenses)

In-Network: $0 copay

Out-Of-Network: 35% coinsurance

Other

Not covered

Upgrades

Not covered

Wellness programs (eg, fitness, nursing hotline)

All service types

Covered

Plan Providers

Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.

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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week

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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.

* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.

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