CurrentBaylor Scott & White Health PlanPolicy N/A

Individual Preferred Provider Organization Insurance Policy

Governs the terms, benefits, enrollment, member rights and responsibilities, and administrative procedures for individual PPO coverage issued by Baylor Scott & White Insurance Company; affects Subscribers and Covered Dependents under the plan.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyIndividual Preferred Provider Organization Insurance Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain preauthorization for services that require it; failure to preauthorize (except emergencies) may result in penalty (lesser of $500 or 50% reduction in benefits).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10 daysfree examination/return period for the policy

60 daysadvance notice for premium changes

844.633.5325customer service

$7,500In-network OOP max

12 monthspreexisting condition exclusion

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage, Benefits, Limits, and Exclusions

Mandated and plan-covered services (excerpt)

Selected Texas-mandated and plan-covered services excerpted from the policy. The items below consolidate statutory-required benefits and related plan provisions referenced in the source document.

Mastectomy and Lymph Node Dissection: The plan provides minimum inpatient coverage for mastectomy and lymph node dissection related to breast cancer as required by Texas law. Coverage includes: 24 hours inpatient stay following a lymph node dissection and 48 hours inpatient stay following a mastectomy unless the member and attending physician determine a shorter period is appropriate. The plan may not deny eligibility, offer payments to encourage accepting less than the minimum inpatient hours, penalize the attending physician for requiring minimum hours, or provide incentives to induce less than the minimum hours. (Reference: 28 TAC S21.2106(b)(1))

Reconstructive Surgery After Mastectomy: The plan provides coverage for reconstructive surgery following mastectomy, including reconstruction of the other breast for symmetry, all stages of reconstruction, prostheses, and treatment of physical complications (e.g., lymphedema). These benefits must be provided in consultation with the member and attending physician. Deductibles and copayments applied are the same as other similar inpatient or medical-surgical expenses per the Schedule of Benefits. The plan may not offer financial incentives to forego reconstruction, condition or limit eligibility to avoid providing coverage, or penalize providers inconsistent with the required coverage. (Reference: 28 TAC S21.2106(b)(2) and federal Women's Health and Cancer Rights Act)

Prostate Cancer Detection: The plan provides benefits for an annual medically recognized diagnostic examination for detection of prostate cancer for each male member. Benefits include a prostate-specific antigen (PSA) test and a physical examination for members who are at least 50 years of age, or at least 40 years of age with a family history or other risk factor. (Reference: 28 TAC S21.2106(b)(4))

Colorectal Cancer Screening: The plan provides coverage for colorectal cancer screening for members age 45 and older at normal risk. Coverage includes an initial colonoscopy or other medically recognized screening test/procedure and a follow-up colonoscopy if the initial test/procedure is abnormal. The plan also covers colorectal cancer examinations, preventive services, and laboratory tests assigned a USPSTF grade of A or B for average-risk individuals. (Reference: 28 TAC S21.2106(b)(3))

HPV, Ovarian, and Cervical Cancer Detection: For women age 18 and older, the plan provides coverage for an annual medically recognized diagnostic examination for early detection of ovarian and cervical cancer. Coverage includes conventional Pap smear or FDA-approved liquid-based cytology alone or combined with an FDA-approved HPV detection test, CA-125 blood test, and other FDA-approved tests for ovarian cancer. (Reference: 28 TAC S21.2106(b)(7))

Acquired Brain Injury Services: The plan covers medically necessary services for acquired brain injury, including cognitive communication therapy, cognitive rehabilitation therapy, neurocognitive therapy and rehabilitation, neurobehavioral/neurophysiological/neuropsychological/psychophysiological testing and treatment, neurofeedback therapy, remediation, reasonable expenses for periodic reevaluation when a previously unresponsive individual becomes responsive, and post-acute community reintegration services (including outpatient day treatment and other post-acute care). Coverage is available regardless of whether hospitalization occurred and may be provided in appropriate licensed facilities. (Reference: 28 TAC S21.3107(a))

Coding, Code Tables, and Key Limits

Imaging definitionsmixed

Definitions related to Diagnostic Imaging and Mammography (Digital Mammography) as provided in Definitions section

Placeholdermixed

Preventive services (no cost-share)mixedCovered

Evidence-based items or services with USPSTF A/B rating; CDC-recommended immunizations; HRSA-supported services covered with no Copayment, Coinsurance, or Deductible

Preventive screening servicesmixed

Screening mammography, Pap/HPV testing, and FDA‑approved ovarian cancer tests (e.g., CA‑125) described with age/frequency criteria

Durable medical equipment / prostheticsmixed

Medically necessary Durable Medical Equipment, Orthotic Devices, and Prosthetic Devices; Prosthetic Devices may require Preauthorization

Radiology and cardiovascular screeningmixed

Outpatient radiological/diagnostic exams (CT, MRI, PET, angiograms, ultrasound) and noninvasive cardiovascular screening tests (carotid IMT, CT coronary artery calcium) with preauthorization and frequency rules

Coding guidance absentmixed

No specific CPT/HCPCS/ICD-10 billing codes listed for cardiovascular screening or biomarker testing in this excerpt; coverage criteria and evidence requirements provided

Prescription and Specialty Drugsmixed

Prescription drug coverage scope and exclusions; Specialty Drugs defined and governed by outpatient Specialty Drugs provision and may require specialty pharmacy dispensing or Medical Director approval

Vision/Refractive exclusionsmixedNot Covered

	Radial keratotomy and other refractive eye surgery excluded
	Traditional or laser vision corrective surgery excluded

Routine care, TMJ, and weight reduction exclusionsmixedNot Covered

	Routine foot care excluded (except when related to systemic conditions)
	Services and supplies for TMJ (except medically necessary diagnostic and surgical procedures) excluded
	Weight reduction services and supplies, including surgical procedures, are not covered

Transplant exclusionsmixedNot Covered

Organ and bone marrow transplants and associated donor/procurement costs are excluded except to the extent specifically listed as covered in this Policy

Plan definitionsmixed

Definition of 'plan' explaining included and excluded types of coverage for Coordination of Benefits

Preventive screening testsmixedCovered

Colorectal cancer screening for age 45+ (including initial and follow-up colonoscopy); Cervical and ovarian cancer screening (Pap/HPV, CA‑125) annually for women 18+; Prostate cancer screening (PSA and exam) annually for males ≥50 or ≥40 with risk factors

Pharmacy coverage requirementsmixedCovered

Covered Prescription Drugs must be dispensed pursuant to a valid prescription by participating health professionals/pharmacies, be FDA‑approved or supported by compendia/peer‑reviewed literature, and meet Formulary/Medical Director requirements

Deductible Calendar Year

Deductible Calendar YearSee Schedule of Benefits (Calendar Year Deductible amounts are specified in the Schedule of Benefits)

Family DeductibleFamily Deductible is cumulative and applies as shown in the Schedule of Benefits

ApplicationDeductible applies to Maximum Out‑of‑Pocket and to amounts described in the Schedule of Benefits

Prior Authorizations, Claims, and Provider Requirements

Prior Authorization

Utilization Review / Preauthorization — Preauthorization Review, Admission Review, Continued Stay Review, Retrospective Review, Failure to Preauthorize

Utilization Review includes preauthorization (prospective review), admission review, retrospective review, and continued stay review to ensure services are Medically Necessary and provided in the appropriate setting. Certain benefits require Preauthorization; a complete list is at BSWHealthPlan.com. Failure to obtain Preauthorization (except for Emergency Care) may result in a penalty of the lesser of $500 or a 50% reduction in benefits. Requests to renew an existing Preauthorization may be submitted beginning 60 days before the authorization expires; We will make reasonable efforts to decide before the existing authorization ends.

Preauthorization (prospective)
Admission review (pre- or post-emergency)
Retrospective review (post-service)
Continued stay review (during admission)

Prior Authorization

Preauthorization — definition and how to request

Preauthorization means prospective Utilization Review by the Issuer or its Utilization Review agent of proposed health care services. Members or Participating Providers should contact the authorization phone number on the Member ID card during business hours and, when required, at least three calendar days prior to an admission or scheduled service that requires Preauthorization. Participating Providers may obtain Preauthorization on a Member's behalf, but the Member remains responsible for ensuring requirements are met.

Claims Processing, Appeals, Complaints, and Recovery

Claims and Appeals Procedures

Claim filing and adjudication requirements and timelines:

Claim filing: Member must submit written proof and Claim acceptable to Issuer, including itemized receipts with date, provider name/address, amount paid, and diagnosis; submit within 90 days when reasonably possible; Issuer has no obligation if not received within 1 year of service date.

Acknowledgement and decision timelines: Issuer will acknowledge receipt within 15 days; will notify acceptance or rejection within 15 business days after receipt of all requested information or, if additional time needed, decisions no later than 45 days after notice; claims paid no later than 5 business days after notification of acceptance.

Complaints and Appeals

Complaints and Appeals process

Complaint timing and process: Members may file Complaints within 180 days; Issuer will acknowledge within 5 business days and investigate/resolve written Complaints within 30 calendar days (emergency or denial of continued hospitalization resolved within 1 business day); appeal available if dissatisfied, with Appeal panel composition and timelines prescribed and final decision notice to include clinical basis and Texas Department of Insurance contact information.

Key Definitions and Terms

Acquired Brain Injury

Acquired Brain Injury definitionAcquired Brain Injury means a neurological insult to the brain, not hereditary, congenital, or degenerative, occurring after birth and resulting in changes in neuronal activity that impair physical functioning, sensory processing, cognition, or psychosocial behavior

Included servicesCoverage may include cognitive rehabilitation, neurocognitive therapy, neurobehavioral/neuropsych testing and treatment, neurofeedback, post‑acute transition and community reintegration services when medically necessary

SettingsServices may be provided in hospitals, rehabilitation hospitals, assisted living or other appropriate facilities; hospitalization not required for coverage

Administer

Administer (definition)To directly apply a drug to the body of a patient by injection, inhalation, ingestion, or any other means

Contacts, Directories, and Notice Requirements

Pharmacy Coverage, Prior Authorization, and Formulary Rules

Pharmacy coverage criteria and restrictions

Coverage for prescription drugs is limited to FDA‑approved/recognized indications, drugs prescribed by participating providers, drugs on or approved as non‑formulary through preauthorization, and drugs dispensed through participating pharmacies/specialty pharmacies when required.

Prescription requirements: Covered prescription drugs must be prescribed by a licensed Participating Health Professional (or in specified emergency/authorized circumstances) and, where required, filled through a Participating Pharmacy or Participating Specialty Pharmacy; Medical Director may require substitution based on Pharmacy & Therapeutics Committee recommendations.

Formulary and preauthorization: Formulary placement managed by Pharmacy & Therapeutics Committee; copayments vary by tier; drugs on Formulary at start of Plan Year remain available at contracted benefit level through Plan Year; non‑Formulary drugs may be covered if medically necessary and formulary alternatives tried or clinically inappropriate; certain drugs require preauthorization and step therapy may apply with statutory exceptions (e.g., stage‑four metastatic cancer, certain serious mental illness drugs).

Dispensing and specialty pharmacy rules: Specialty drugs generally must be dispensed by a participating specialty pharmacy; failure to use required dispensing channel may result in denial; restrictions may include step therapy, quantity limits, and one preauthorization per Member per drug per year for certain conditions with enumerated exceptions.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyIndividual Preferred Provider Organization Insurance Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain preauthorization for services that require it; failure to preauthorize (except emergencies) may result in penalty (lesser of $500 or 50% reduction in benefits).

SourceLink

On This Page

Specialty Drug cost threshold

Specialty Drug thresholdAny Prescription Drug with total cost greater than $1,000 per prescription meets the Specialty Drug definition

Other specialty criteriaAlso includes drugs requiring complex benefit review, specialized handling/distribution, or complex medical management

Program implicationOutpatient specialty drugs are governed by the outpatient Specialty Drug benefit and may require specialty pharmacy dispensing

Preauthorization penalty

Preauthorization penaltyFailure to obtain required Preauthorization (except Emergency Care) results in the lesser of $500 or a 50% reduction in benefits

ScopePenalty applies to benefits that require Preauthorization as listed on BSWHealthPlan.com and in the Schedule of Benefits

ExceptionEmergency Care is exempt from the Preauthorization penalty

Maximum Out-of-Pocket credit condition

MOOP credit conditionCash payments made directly to a provider may be credited toward the Deductible and Maximum Out‑of‑Pocket if the amount paid is less than the average discounted rate under the Plan and the claim is not submitted to the Issuer

DocumentationProcedures and documentation required to claim a credit are available at BSWHealthPlan.com

Network statusCredit may be applied regardless of provider network status if conditions are met

Annual maximum benefit

Annual maximum benefitCoverage is provided up to the maximum benefit per Calendar Year as specified in the Schedule of Benefits

DME exampleDurable medical equipment coverage is limited to the per‑Calendar‑Year maximum shown in the Schedule of Benefits

DeterminationSpecific maximums and applicability are governed by the Schedule of Benefits and policy provisions

Outpatient non-specialty drug single-dose cost threshold

Single‑dose outpatient non‑specialty thresholdOutpatient non‑specialty drugs administered in an outpatient setting that cost $450 or more for a single dose may require Preauthorization

SettingApplies to non‑specialty drugs dispensed and administered in a provider office or outpatient setting (medical benefit)

Preauthorization consequenceSuch high‑cost single doses may require Issuer Preauthorization to be covered as a medical benefit

Outpatient non-specialty drug 12-month refill cost threshold

12‑month refill thresholdRefillable outpatient non‑specialty prescriptions whose total cost during a 12‑month period could equal or exceed $1,000 may require Preauthorization

Coverage noteApplies to drugs dispensed/administered in outpatient settings and may trigger Preauthorization requirements

Exclusion if not authorizedWithout Issuer approval, coverage for certain outpatient pharmacy‑dispensed/administered drugs may be excluded unless a Prescription Drug Rider applies

Cardiovascular screening frequency

Screening frequencyOne noninvasive cardiovascular atherosclerosis/artery structure/function screening test every 5 years

Eligible membersMales >45 and <76; females >55 and <76; members must have diabetes or intermediate‑or‑higher Framingham risk score

Covered testsIncludes carotid intima‑media ultrasound and preauthorized CT coronary artery calcium scoring when medically necessary

Preexisting condition period and prescription age limit

Preexisting condition periodBenefits for treatment of a Preexisting Condition are excluded for 12 months from a Member's Effective Date

Prescription age limitAny initial or refill prescription dispensed more than one (1) year after the date of the Physician's order is excluded from the Prescription Drug benefit

Creditable coverage notePreexisting condition rules are subject to the Preexisting Conditions provision and any applicable creditable coverage exceptions

Bodily fluid storage duration

Storage duration exclusionLong‑term storage (longer than 6 months) of blood and blood products is excluded; storage of semen, ova, bone marrow, stem cells, DNA, or any other bodily fluid or body is excluded unless approved by the Medical Director

Medical Director exceptionStorage beyond 6 months may be covered only if approved by Our Medical Director

ScopeApplies to storage of blood, blood products, reproductive materials, stem cells, DNA and other bodily fluids/body parts

Claim payment timing

Claim payment timingClaims will be paid no later than 5 business days after notification of acceptance

Acknowledgement and decision timingIssuer will acknowledge receipt within 15 days and decide within 15 business days after receipt of all requested information (may extend up to 45 days with notice)

Payment to providerPayment to the provider discharges the Issuer's obligation under the policy

Secondary Plan Payment Limit

Secondary plan payment limitWhen this plan is secondary, it may reduce benefits so that total payments from all plans equal 100% of the total allowable expense

Calculation methodSecondary plan calculates what it would have paid absent other coverage and then reduces payment so combined payments do not exceed allowable expense; deductible credits applied accordingly

Credits to deductibleThe secondary plan must credit amounts it would have credited to its Deductible in the absence of other coverage

Out-of-Pocket and Specialty Drug Deductible

In‑network Out‑of‑Pocket maximumIn‑network individual Maximum Out‑of‑Pocket listed as $7,500 (per Schedule of Benefits)

Specialty drug outpatient deductibleOutpatient specialty drug deductible (in‑network) is $250 prior to specialty drug coverage applying

Non‑preferred specialty drug noteCopayments for Non‑Preferred Specialty Drugs are not considered Out‑of‑Pocket Expenses for meeting the Maximum Out‑of‑Pocket

Formulary evidence availability

Formulary evidence availabilityPharmacy & Therapeutics Committee defines timeframe for Formulary selection as at least 180 days of availability before placing a drug on the Formulary

Committee roleCommittee (physicians and pharmacists) meets at least quarterly to review evidence, economics, and other information for Formulary placement

NotificationModifications to the Formulary are provided in writing to the commissioner and affected Members at least 60 days before effective date

Call authorization number on Member ID Card
Request at least 3 calendar days prior to scheduled service when required
Participating Provider may request on Member's behalf

Denial Risk

Adverse Determinations and Appeals Access — provider opportunity to discuss prior to adverse determination

When We question the Medical Necessity or appropriateness of a requested service prior to issuing an Adverse Determination, the Participating Provider who ordered the service will be given a reasonable opportunity to discuss the Member's treatment plan and the clinical basis of Our determination with Our Medical Director. If We determine a proposed benefit is not Medically Necessary, the Member and/or Participating Provider will be notified in writing within three days with the clinical basis, principal reasons, screening criteria sources used, and instructions for Complaint and Appeal procedures including Independent Review Organization rights.

Reasonable opportunity to discuss with Medical Director prior to Adverse Determination
Written notice within 3 days if not Medically Necessary: clinical basis, reasons, criteria sources, appeal procedures

Note

Internal appeal initiation and reviewer qualification

Providers, Members, or persons acting on a Member's behalf may request an internal appeal orally or in writing. Members have 180 days from receipt of an Adverse Determination to file an internal Appeal; We will acknowledge the Appeal within five working days. Appeals are reviewed by a clinical peer reviewer in the same or similar specialty who was not subordinate to the initial reviewer. For life‑threatening conditions or for certain Prescription Drug or infusion matters, Members have immediate rights to Independent Review without first requesting an internal review.

180 days to file internal Appeal
Acknowledgement within 5 working days
Clinical peer reviewer in same/similar specialty
Immediate Independent Review available for life‑threatening conditions and certain drug/infusion issues

Note

Expedited internal appeal access for providers

Providers may request an expedited internal appeal for urgent matters including denials of Emergency Care, continued hospitalization, Prescription Drugs for which the Member is receiving benefits, and step therapy exception requests. For expedited appeals, the provider must have reasonable access to the clinical peer reviewer within one business day. Expedited appeals will be decided within the earlier of 72 hours of receipt or one business day after receipt of necessary information.

Reasonable access to clinical peer reviewer within 1 business day
Decision within 72 hours or 1 business day after necessary info received
Applicable to Emergency Care, continued hospitalization, certain drug/step therapy issues

Prior Authorization

Emergency post-stabilization authorization

Once a Member is stabilized after Emergency Care, any further treatment (post‑stabilization care) requires approval by Us and may require authorization by Our Medical Director. Members who receive emergency care from a Non‑Participating Provider should notify Us as soon as reasonably possible (within 48 hours if reasonably possible) to obtain assistance transitioning care and to obtain any required approvals for post‑stabilization services.

Post‑stabilization care requires Our approval/authorization
Notify Issuer as soon as reasonably possible if treated by Non‑Participating Provider (within 48 hours when possible)
We may facilitate transport to a Participating Facility after stabilization with Medical Director authorization

Billing Rule

Home infusion and device preauthorization/payment

Home Infusion Therapy is covered when approved by the Issuer as Medically Necessary and includes high‑technology services (e.g., line care, chemotherapy, pain management, antibiotic/antiviral/antifungal therapy), administrative and professional pharmacy services, and necessary supplies and equipment for home infusion. Specialty Drugs administered via home infusion are covered under the Specialty Drug benefit and subject to applicable Specialty Drug cost sharing; some infusion‑related professional services and certain DME may be covered under other Policy provisions and cost sharing.

Home infusion covers line care, chemotherapy, pain management, antibiotic/antiviral/antifungal therapy
Specialty Drugs via home infusion billed under Specialty Drug benefit and subject to Specialty Drug copays
Members responsible for Deductible, Coinsurance and Copayments per Schedule of Benefits

Prior Authorization

Cardiovascular Screening Preauthorization

Certain cardiovascular screening tests are available once every five years when performed by a certified facility or provider. Ultrasonography measuring carotid intima‑media thickness/plaque and CT scanning measuring coronary artery calcification are covered when preauthorized as Medically Necessary. Coverage applies to Members meeting age and risk criteria (e.g., males 46–75, females 56–75, or Members with diabetes or intermediate/higher Framingham risk score).

Ultrasonography for carotid intima‑media thickness and plaque (every 5 years)
CT coronary artery calcification scanning requires Preauthorization as Medically Necessary
Age/risk eligibility: males >45–<76, females >55–<76, or diabetes/intermediate+ Framingham risk

Billing Rule

Claim Acknowledgement, Decision, and Payment Timelines; Payment to Provider

Claims will be acknowledged in writing no later than 15 days after receipt; the Issuer will notify acceptance or rejection no later than 15 business days after receipt of all requested information (or within 45 days if an extension is required). Payment of accepted claims will be made no later than the fifth business day after notification of acceptance. Payment by the Issuer to the provider discharges the Issuer's obligations under the Policy.

Acknowledge receipt of Claim within 15 days
Notify acceptance/rejection within 15 business days after receipt of all items (or by 45th day if extension)
Pay accepted claims within 5 business days after acceptance
Payment to provider discharges Issuer's obligations

Documentation Required

COVID-19 documentation policy

Baylor Scott & White Insurance Company will not require a prospective or current Member to provide documentation certifying COVID‑19 vaccination or post‑infection recovery as a condition for obtaining coverage or receiving benefits under this Plan. Members with questions may call 844.633.5325 or write to the Issuer at 1206 W. Campus Drive, Temple, Texas 76502.

No vaccine or post‑infection documentation required to obtain coverage or benefits
Contact: 844.633.5325 or 1206 W. Campus Drive, Temple, TX 76502

Step Therapy

Pharmacy authorization and step therapy rules

Pharmacy authorization and utilization management may include step therapy, quantity limits, and preauthorization for certain medications. Step therapy requires trial of an alternative drug(s) before coverage of the requested drug unless statutory or clinical exceptions apply (for example, stage‑four metastatic cancer drugs meeting criteria and Serious Mental Illness rules). Preauthorization requires submission of documentation demonstrating Medical Necessity. Members and providers may appeal Adverse Determinations for drugs; step therapy exception requests may be granted if not denied within timeframes (72 hours general; 24 hours if denial could result in death or serious harm). No more than one preauthorization per Member per year per drug is required for treatments for certain rare conditions (with listed exceptions). Refer to BSWHealthPlan.com for specific drug lists and submission procedures.

Step therapy protocols and exception process
Quantity limits may apply
Preauthorization required for certain drugs and refill thresholds (e.g., single‑dose cost ≥ $450 or 12‑month cost ≥ $1,000 for non‑specialty outpatient drugs)
Exception timelines: step therapy exception considered granted if not denied within 72 hours (or 24 hours if life‑threatening risk)

Arbitration

Voluntary binding arbitration option

Arbitration: After exhaustion of appeals, disputes over damages may be submitted to voluntary binding arbitration administered by AAA under Healthcare Payor Provider Arbitration Rules if both parties agree; single arbitrator with >=15 years' relevant experience; governed by Texas law; confidentiality restrictions apply.

Medicare and Coordination of Benefits

Medicare coordination and effect on benefits

Medicare coordination: When Medicare is primary, Member must maintain Medicare Part B and cooperate in coordination; Issuer will pay difference between Allowable Expense and Medicare payment and charge amounts against applicable benefit limitations; Issuer may pay other organizations to satisfy intent of provision and such payments discharge Issuer liability.

Subrogation, Recovery, and Participant Obligations

Subrogation, right to recovery, assignment, reimbursement and plan actions

Subrogation and recovery: Plan is subrogated to all rights of recovery to extent of benefits paid; right to recover overpayments, mistaken payments, and payments due to participant misrepresentation; Plan may require return of overpayment or offset future benefits and may take actions including ceasing benefit payments, bringing suit, or designating agents to recover; participant obligations include notice of claims, cooperation, and obtaining Plan consent before settling claims.

Coordination of Benefits and Recovery Criteria

Rules governing how this Plan pays when other coverage exists and how benefits are coordinated.

Coordination of Benefits: Primary plan pays per its terms; when this plan is secondary it may reduce benefits so combined payments equal 100% of allowable expense and will calculate what it would have paid absent other coverage and credit deductible amounts accordingly; closed panel exceptions and detailed order of benefit determination rules apply (birthday rule, length of coverage, COBRA/continuation rules, tie‑breakers).

Participant obligations and remedies: Participant must notify Plan Sponsor of potential claims, cooperate, provide information, authorize Plan to pursue recovery; Plan may cease benefits, bring actions, or require Plan be named as co‑payee on settlements.

ContextUsed to classify clinician‑administered drugs versus self‑administered medications in benefit determinations

ImplicationCertain clinician‑administered outpatient drugs may be treated as medical benefit when administered in office settings

Amino Acid-Based Elemental Formulas

Amino Acid‑Based Elemental FormulasComplete nutrition formulas designed for Members with immune responses to allergens in whole‑food or whole‑protein formulas; made from single nonallergenic amino acids for easy absorption

CoverageMay be covered when ordered by a Participating Provider and Medically Necessary, up to the calendar year maximum in the Schedule of Benefits

Administration and limitsAdministration services are covered and subject to applicable cost sharing; specific limits referenced in Schedule of Benefits

Coinsurance

Coinsurance (definition)The percentage of Covered Expenses You are responsible for paying after applicable Deductibles are satisfied; excludes non‑covered charges or amounts exceeding Covered Expenses

ApplicationSpecific coinsurance amounts for services are shown in the Schedule of Benefits; coinsurance does not include charges for non‑covered services

Effect on MOOPCoinsurance payments count toward Out‑of‑Pocket unless otherwise specified (e.g., some specialty drug copays may be excluded)

Covered Expenses

Covered Expenses (definition)Expenses incurred for covered benefits, subject to Deductibles and other benefit limits; for Participating Providers will not exceed contracted rates; for Non‑Participating Providers will not exceed Usual and Customary Rates

LimitsCovered Expenses may be limited by specific maximums described in this Plan and the Schedule of Benefits (e.g., per‑Calendar‑Year DME maximums)

Date incurredAn expense is incurred on the date the Member receives the covered benefit

Medically Necessary / Medical Necessity

Medically Necessary / Medical NecessityServices which, in the opinion of a Member's Participating Provider and subject to review by the Medical Director or Quality Assurance Committee, are clinically appropriate in type, frequency, extent, site and duration, effective, not primarily for convenience, and not more costly than alternatives

Reviewer roleMedical Director and Quality Assurance Committee review determinations and may overturn provider opinion if not meeting criteria

Coverage implicationBenefits are payable only when services are Medically Necessary as defined in the policy

Participating Provider / Our Right to Contract

Participating Provider / Our Right to ContractParticipating Providers are contracted independent contractors; Issuer is not agent of providers; Members entitled to covered benefits from Participating and Non‑Participating Providers subject to Schedule of Benefits and Policy

Member protectionsParticipating Providers must make reasonable efforts to maintain patient relationships; members not liable for provider acts/omissions beyond applicable cost sharing

Network accessMembers can access provider lists and network information at BSWHealthPlan.com

Specialty Drug

Specialty Drug (definition)Any Prescription Drug requiring complex benefit review, specialized handling or monitoring, or with total cost greater than $1,000 per prescription

Examples/criteriaMay include orally administered anticancer agents or drugs requiring FDA‑mandated comprehensive patient/physician education or complex medical management

Program implicationOutpatient Specialty Drugs follow the outpatient Specialty Drug benefit and may require specialty pharmacy dispensing and distinct cost sharing

Adverse Determination

Adverse Determination (definition)A determination by Us or Our designated Utilization Review organization that the benefits provided or proposed are not Medically Necessary or are Experimental or Investigational

Appeal pathAdverse Determinations are subject to internal appeal and, if denied, independent review under Chapter 4202 of the Texas Insurance Code

DocumentationIssuer will provide relevant records and documents to the Independent Review Organization within 3 business days of receiving a request

Final Internal Adverse Determination

Final Internal Adverse DeterminationAn Adverse Determination that has been upheld after completion of the Issuer's internal review and appeal process

Next stepParties whose appeal is denied may seek Independent Review in accordance with Texas law

Binding natureIssuer will comply with Independent Review Organization determinations regarding Medical Necessity or Experimental/Investigational status

Experimental or Investigational

Experimental or InvestigationalProcedures or treatments considered Experimental or Investigational are excluded (not covered) for transplants and otherwise as stated in Exclusions

Transplant exceptionTransplants are covered only if not Experimental/Investigational and approved by Medical Director and meet Plan criteria

Appeal implicationDenials based on Experimental/Investigational determinations are Adverse Determinations and subject to appeals and independent review

Biomarker Testing

Biomarker Testing coverageBiomarker testing is covered for diagnosis, management, or monitoring when supported by FDA drug indication, FDA‑cleared/approved test labeling, CMS national/local coverage determination, consensus statements, or nationally recognized clinical practice guidelines

Evidence requirementCoverage requires supporting medical and scientific evidence as listed in policy

Use casesIntended to guide treatment decisions when sufficiently supported by evidence

Telehealth/Telemedicine

Telehealth/TelemedicineTelehealth and Telemedicine Medical Services are covered and are subject to the same terms and conditions as in‑person benefits; an in‑person consultation is not required

AccessAdditional information available at BSWHealthPlan.com

ParityTelehealth benefits follow the same coverage rules, cost sharing and limitations as equivalent in‑person services

Plan

Plan (definition)A 'Plan' is any arrangement providing medical, dental, or vision benefits (group or individual insurance, HMOs, self‑funded arrangements, Medicare where permitted, and related coverages)

Inclusions/ExclusionsLists examples of included and excluded arrangements to clarify what constitutes a Plan for coordination rules

COB contextDefinition used in Coordination of Benefits provisions to determine applicability

Formulary

Formulary (definition)A Formulary is an evidence‑based list of Prescription Drugs developed by the Pharmacy & Therapeutics Committee for which the Issuer provides coverage

Committee processPharmacy & Therapeutics Committee reviews evidence and economic data, meets at least quarterly, and defines placement/timeframe (180 days) for Formulary consideration

Member noticeModifications to the Formulary are communicated to the commissioner and affected Members at least 60 days prior to effective date