BSW Prime Silver HMO 003 (CMS Standardized Plan with $0 Pediatric PCP copay)
Baylor Scott and White Health Plan · 2026 plan year
Silver
- Ind. deductible
- $6,000
- Family deductible
- $12,000
- Ind. OOP max
- $8,900
- Family OOP max
- $17,800
Compare with other Silver plans in TX
Side by side: deductibles, out-of-pocket limits and copays.
Other cost-sharing reduction variants for this plan:
More Baylor Scott and White Health Plan plans in TX
Monthly premiums by age
Rating Area 24 — the lowest-priced of the 14 areas this plan covers. Premiums differ by area.
| Age | Individual | Individual + tobacco |
|---|---|---|
| Under 15 | $337 | $337 |
| 21 | $441 | $661 |
| 30 | $500 | $750 |
| 40 | $563 | $844 |
| 50 | $787 | $1,180 |
| 60 | $1,196 | $1,793 |
| 64 and over | $1,322 | $1,982 |
Live premium estimate
Benefits & cost sharing
Primary Care
| Benefit | In-network |
|---|---|
| Preventive Care/Screening/Immunization | No charge |
| Primary Care Visit to Treat an Injury or Illness | $40.00 |
Specialist
| Benefit | In-network |
|---|---|
| Specialist Visit | $80.00 |
Hospital
| Benefit | In-network |
|---|---|
| Emergency Room Services | 40.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay) | 40.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services | 40.00% Coinsurance after deductible |
| Urgent Care Centers or Facilities | $60.00 |
Pharmacy
| Benefit | In-network |
|---|---|
| Generic Drugs | $20.00 |
| Non-Preferred Brand Drugs | $80.00 Copay after deductible |
| Off Label Prescription Drugs | $80.00 Copay after deductible |
| Preferred Brand Drugs | $40.00 |
| Prescription Drugs Other | $80.00 Copay after deductible |
| Specialty Drugs | $350.00 Copay after deductible |
Mental Health
| Benefit | In-network |
|---|---|
| Mental/Behavioral Health Inpatient Services | 40.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services | $40.00 |
Other
| Benefit | In-network |
|---|---|
| Habilitation Services | $40.00 |
| Abortion for Which Public Funding is Prohibited | Not covered |
| Accidental Dental | 40.00% Coinsurance after deductible |
| Acupuncture | Not covered |
| Allergy Testing | 40.00% Coinsurance after deductible |
| Autism Spectrum Disorders | $40.00 |
| Bariatric Surgery | Not covered |
| Basic Dental Care - Adult | Not covered |
| Basic Dental Care - Child | Not covered |
| Brain Injury | 40.00% Coinsurance after deductible |
| Chemotherapy | 40.00% Coinsurance after deductible |
| Chiropractic Care | $40.00 |
| Cosmetic Surgery | Not covered |
| Delivery and All Inpatient Services for Maternity Care | 40.00% Coinsurance after deductible |
| Dental Check-Up for Children | Not covered |
| Diabetes Care Management | $40.00 |
| Diabetes Education | $40.00 |
| Dialysis | 40.00% Coinsurance after deductible |
| Durable Medical Equipment | 40.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | 40.00% Coinsurance after deductible |
| Eye Glasses for Children | $80.00 |
| Hearing Aids | 40.00% Coinsurance after deductible |
| Home Health Care Services | 40.00% Coinsurance after deductible |
| Hospice Services | 40.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs) | 40.00% Coinsurance after deductible |
| Infertility Treatment | Not covered |
| Infusion Therapy | 40.00% Coinsurance after deductible |
| Inherited Metabolic Disorder - PKU | 40.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | 40.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services | 40.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care | Not covered |
| Major Dental Care - Adult | Not covered |
| Major Dental Care - Child | Not covered |
| Nutritional Counseling | $40.00 |
| Orthodontia - Adult | Not covered |
| Orthodontia - Child | Not covered |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $40.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 40.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services | $40.00 |
| Pediatric Services Other | 40.00% Coinsurance after deductible |
| Post-Mastectomy Care | 40.00% Coinsurance after deductible |
| Prenatal and Postnatal Care | $40.00 |
| Private-Duty Nursing | 40.00% Coinsurance after deductible |
| Prosthetic Devices | 40.00% Coinsurance after deductible |
| Radiation | 40.00% Coinsurance after deductible |
| Reconstructive Surgery | 40.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $40.00 |
| Rehabilitative Speech Therapy | $40.00 |
| Routine Dental Services (Adult) | Not covered |
| Routine Eye Exam (Adult) | Not covered |
| Routine Eye Exam for Children | $80.00 |
| Routine Foot Care | Not covered |
| Skilled Nursing Facility | 40.00% Coinsurance after deductible |
| Substance Abuse Disorder Inpatient Services | 40.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services | $40.00 |
| Transplant | 40.00% Coinsurance after deductible |
| Transplant Donor Coverage | 40.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders | 40.00% Coinsurance after deductible |
| Weight Loss Programs | Not covered |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | 40.00% Coinsurance after deductible |
Plan rules
Service area
This plan covers 104 geographic areas.
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