BSW SeniorCare Advantage Platinum (PPO)

BSW SeniorCare Advantage Platinum (PPO) H2032-003 Plan Details
4 out of 5 stars

BSW SeniorCare Advantage Platinum (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Scott and White Health Plan.
Plan ID: H2032-003.

$140.00
Monthly Premium

BSW SeniorCare Advantage Platinum (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Scott and White Health Plan.
Plan ID: H2032-003.

BSW SeniorCare Advantage Platinum (PPO) H2032-003 Plan Details
4 out of 5 stars

BSW SeniorCare Advantage Platinum (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Scott and White Health Plan.
Plan ID: H2032-003.

$140.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $50
Out of Pocket Max In-Network: $4700
Out-of-Network: 10000
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
Out-of-Network:

Doctor Office Visit:
Coinsurance for Medicare Covered Primary Care Office Visit 30%
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $20.00
Out-of-Network:

Doctor Specialty Visit:
Coinsurance for Medicare Covered Physician Specialist Office Visit 30%
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$250.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Maximum out of Pocket $1250.00
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Out-of-Network:
30% per day for days 1 to 5
30% per day for days 6 to 90
Urgent Care
Copayment for Urgent Care $50.00
Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours
Emergency Room Visit
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $75.00

Air Ambulance:
Copayment for Air Ambulance Services $75.00

Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required
Out-of-Network:

Ambulance Services:
Coinsurance for Medicare Covered Ambulance Services - Ground 30%
Coinsurance for Medicare Covered Ambulance Services - Air 30%

Health Care Services and Medical Supplies

BSW SeniorCare Advantage Platinum (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Copayment for Medicare-covered Chiropractic Services $20.00
Out-of-Network:
Coinsurance for Medicare Covered Chiropractic Services 30%
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Copayment for Medicare-covered Diabetic Supplies $0.00
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00
Out-of-Network:
Coinsurance for Medicare Covered Diabetic Supplies and Services 30%
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Durable Medical Equipment 30%
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00
Copayment for Medicare-covered Lab Services $0.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $20.00 to $200.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 30%
Coinsurance for Medicare Covered Lab Services 30%
Coinsurance for Medicare Covered Diagnostic Radiological Services 30%
Coinsurance for Medicare Covered Therapeutic Radiological Services 30%
Coinsurance for Medicare Covered Outpatient X-Ray Services 30%
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Home Health 30%
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$250.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:
30% per day for days 1 to 5
30% per day for days 6 to 90
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $20.00
Copayment for Medicare-covered Group Sessions $20.00
Out-of-Network:
Coinsurance for Medicare Covered Individual Sessions 30%
Coinsurance for Medicare Covered Group Sessions 30%
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $100.00
Coinsurance for Medicare Covered Outpatient Hospital Services 20%
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Coinsurance for Medicare Covered Observation Services 20%

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $75.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Out-of-Network:

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 30%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 30%
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $45.00
Copayment for Medicare-covered Group Sessions $45.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Individual or Group Sessions 30%
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $45.00
Out-of-Network:
Coinsurance for Medicare Covered Podiatry Services 30%
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$50.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required
Out-of-Network:
30% per day for days 1 to 20
30% per day for days 21 to 100

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Preventive Dental:
Copayment for Oral Exams $0.00
  • Maximum 1 visit every six months
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 1 visit every six months
Copayment for Dental X-Rays $0.00
  • Maximum 1 visit every three years
Maximum Plan Benefit of $2000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental:
Copayment for Medicare-covered Benefits $0.00
Copayment for Diagnostic Services $0.00
  • Maximum 1 visit every six months
Copayment for Restorative Services $0.00
  • Maximum 1 visit every two years
Coinsurance for Extractions 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $2000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined
Out-of-Network:

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 30%
Non-Medicare Covered Dental Services:
Copayment for Non-Medicare Covered Preventive Dental $0.00
Coinsurance for Non-Medicare Covered Comprehensive Dental 50%

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $40.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Contact Lenses $0.00
  • Maximum 12 Pairs every year
Copayment for Eyeglasses (lenses and frames) $0.00
  • Maximum 1 Pair every year
Copayment for Eyeglass Lenses $0.00
  • Maximum 1 Pair every year
Copayment for Eyeglass Frames $0.00
  • Maximum 1 Pair every year
Maximum Plan Benefit of $125.00 every year for all Non-Medicare covered eyewear for in and out of network services combined
Out-of-Network:

Medicare Covered Vision Services:
Coinsurance for Medicare Covered Eye Exams 30%
Coinsurance for Medicare Covered Eyewear 30%
Non-Medicare Covered Vision Services:
Coinsurance for Non-Medicare Covered Eye Exams 30%
Coinsurance for Non-Medicare Covered Eyewear 30%

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $20.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
  • Maximum 1 visit every year

Hearing Aids:
Copayment for Hearing Aids $0.00
  • Maximum 1 Hearing Aids every three years
Maximum Plan Benefit of $1000.00 every three years both ears combined for in and out of network services combined
Out-of-Network:

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 30%
Non-Medicare Covered Hearing Services:
Coinsurance for Non-Medicare Covered Hearing Exams 30%
Coinsurance for Non-Medicare Covered Hearing Aids 30%

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit
    Out-of-Network:

    Medicare-covered Zero Dollar Preventive Services:
    Coinsurance for Medicare Covered Medicare-covered Preventive Services 30%

    Prescription Drug Costs and Coverage

    The BSW SeniorCare Advantage Platinum (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $50 (excludes Tiers 1 and 2) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $50 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard retail $2.00
    • Standard mail order $0.00
    Generic
    • Standard retail $12.00
    • Standard mail order $0.00
    Annual Drug Deductible $50 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard retail $4.00
    • Standard mail order $0.00
    Generic
    • Standard retail $24.00
    • Standard mail order $0.00
    Annual Drug Deductible $50 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard retail $4.00
    • Standard mail order $0.00
    Generic
    • Standard retail $24.00
    • Standard mail order $0.00