Here are details for PPO Basic

If you’d like help choosing a Medicare Advantage plan from Baylor Scott & White Health Plan, please call 833.975.0841833.975.0841 (TTY: 711) to speak to a licensed insurance agent.

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PPO Basic (Central Texas)

Monthly Premium $0

Deductible $0

Out-of-Pocket Maximum $6,750

Annual Physical Exam $0 copay

Primary Care Physician (PCP) Office Visit $0 copay

Specialty Care Physician (SCP) Office Visit $35 copay

Telehealth Visit (PCP, SCP, Psychiatry Services) $0 copay

Diagnostic Tests, X-rays, Lab Services(separate office visit copay may apply) $0 copay

Advanced Diagnostic Imaging Services (MRI, MRA, SPECT, CTA) $0-$300 copay

Physical/Occupational/Speech Therapy(per visit) $35 copay

Inpatient Hospital Day 1-6: $325/day per stay
Day 7-90: $0/day per stay

Inpatient Mental Health Day 1-5: $318/day per stay
Day 6-90: $0/day per stay

Skilled Nursing Facility (SNF) Day 1-20: $0/day
Day 21-100: $218/day

Outpatient Surgery(facility) $350 copay

Ambulatory Surgical Center(facility) $275 copay

Ambulance(ground and air) $325 copay

Emergency Care(within the U.S.; copay waived if admitted within 24 hours) $130 copay

Urgent Care(within the U.S.; copay waived if admitted within 24 hours) $50 copay

Durable Medical Equipment (DME) 20% coinsurance

Podiatry $45 copay

Chemotherapy Drugs 0%-20% coinsurance

Other Part B Drugs 0%-20% coinsurance

Heart Health Program Not applicable

Deductible $250 (Applies to Tiers 3-5)

Tier 1 – Preferred Generic Drugs (30-day supply) $0/$5 copay

Tier 2 – Generic Drugs (30-day supply) $7/$14 copay

Tier 3 – Preferred Brand Drugs (30-day supply) $47/$47 copay

Tier 4 – Non-Preferred Drugs (30-day supply) 35% coinsurance

Tier 5 – Specialty Drugs (30-day supply) 30% coinsurance

Mail Order Copays (90-day supply) Tiers 1 – 2 are $0 copay;
Tier 3 is two copays;
Tier 4 is 35% coinsurance

Total Out-of-Pocket You Pay Before Catastrophic Coverage $2,100

Catastrophic Coverage Amounts – You Pay $0 copay

Monthly Premium Included

Yearly Benefit Maximum $3,000

Deductible $0

Oral Exams (One every 6 months) $0

Cleanings (One every 6 months) $0

Dental X-rays $0

Extractions 50% coinsurance

Fillings (One filling per surface, per tooth every 24 months) 50% coinsurance

Dentures (every 5 years) 50% coinsurance

Routine Eye Exam(one per year; must use a network provider) $0 copay

Eyewear(annually; must use network provider) $150 allowance

Routine Hearing Exam(one per year) $0 copay

Hearing Aids(every 3 years) $1,000 allowance

Fitness Membership (Home fitness programs, activity tracker, and/or gym/fitness club membership at participating locations) $0

Want help comparing your plans and benefits—and finding the right choice for your needs? Are you ready to enroll?

Call 833.975.0841833.975.0841 (TTY: 711) to speak with a licensed insurance agent.

October 1 – March 31: 7 days a week, 8:00 AM – 8:00 PM
April 1 – September 30: Monday – Friday, 8:00 AM – 5:00 PM
Closed on major holidays.

Para hablar con un representante en español, llame a 833.412.3320833.412.3320.

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