Benefits of membership guide Form

Y005826NTXBOMC 2026 North Texas Benefits of Membership

1 We are glad to have you as a member These days, many health plans compete for your membership, and we’re glad you chose Baylor Scott & White Health Plan. With affordable copays, no referrals required to see a specialist, and access to renowned Baylor Scott & White Health system providers and hospitals throughout Central, North and West Texas, you can be confident Baylor Scott & White Health Plan is the right choice for your healthcare needs. This guide provides contact information you may need throughout your journey with us, and shares helpful tips on how to manage your benefits and your healthcare experience. Contact information at a glance Baylor Scott & White Customer Service Health Plan 1.866.334.3141 • TTY: 711 Oct. 1 - March 31: 7 days a week,
7 AM to 8 PM. Closed on major holidays. April 1 - Sept. 30: Monday-Friday,
7 AM to 8 PM. Closed on major holidays.
Customer Engagement (Plan Changes/Annual Enrollment Assistance) 1.877.845.3901 8 AM to 5 PM • Monday–Friday Email: HPCustomerEngagement@BSWHealth.org MetLife Dental 1.855.676.9337

                                                                   MetLife.com

Mail Order Prescriptions 1.833.502.3340

Silver&Fit 1.877.427.4788 • TTY: 711 (fitness benefit) SilverandFit.com

OTC Card 1.866.334.3141 • TTY: 711
(over-the-counter) Baylor Scott & White Health Plan Customer Service Modivcare (transportation 1.866.428.0212 benefit for HMO-POS plans) Modivcare.com Medicare 1.800.MEDICARE (1.800.633.4227)

     TTY: 1.877.486.2048 
     24 hours a day/7 days a week 
     Medicare.gov

Baylor Scott & White Health Plan offers BSW SeniorCare Advantage HMO-POS plans as a Medicare Advantage (MA) organization through a contract with Medicare. Baylor Scott & White Insurance Company offers BSW SeniorCare Advantage PPO plans as an MA organization through a contract with Medicare. Enrollment in one of these plans depends on the health plan’s contract renewal with Medicare. Other pharmacies, physicians and providers are available in our network.

2 3 How your plan works You don’t have to have a primary care physician to get the care you need. You can see a specialist without a referral anytime. You can find in-network doctors, specialists, hospitals and other providers online through BSWHealthPlan.com/FindProvider or by calling Customer Service. HMO-POS Except for urgent and emergency care, you must get your care and services from in-network providers. If you choose to
get non-emergency or non-urgent services
out of network, you will be personally responsible for payment of all out-of- network charges. PPO Except for urgent and emergency care, you will pay more out of pocket when you visit out-of-network providers, because your out-of-network healthcare services are subject to a higher deductible and coinsurance percentage. Refer to your plan’s Evidence of Coverage at BSWHealthPlan.com/Medicare for details.
Out-of-network/non-contracted providers are under no obligation to treat members, except in emergency situations. Please call Customer Service or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. Preventive care is covered at 100% Preventive services are covered at 100% (no copay) when you use in-network providers for services such as: For a complete list of covered preventive services, refer to your plan’s Evidence of Coverage at BSWHealthPlan.com/Medicare. Annual wellness visits Immunizations Cancer screenings Here to help you Call Customer Service for answers to benefits questions or claims inquiries, or help finding providers and using online tools. 1.866.334.3141 (TTY: 711) Where to go for care Choosing the right option for your condition can save you time and money. VIRTUAL CARE—$0 COPAY Using your mobile device or computer. For conditions such as allergies, bladder infections, colds, flu, pink eye, quitting tobacco, sinus infections, stomach problems or yeast infections. PRIMARY CARE DOCTOR Another choice for care when it’s not an emergency. For conditions such as asthma, diabetes management, earaches, high blood pressure, headaches, preventive health, sprains and more. WALK-IN CLINICS Same-day appointments when your doctor is not available. Includes select primary care clinics and some pharmacy locations. For conditions such as asthma, bladder infections, ear or sinus pain, flu, sore throat or sprains. URGENT CARE Needs immediate attention but is not life-threatening, or an appointment is not available with your doctor. For conditions such as back pain, bladder infections, earaches, minor burns, minor eye injuries, minor cuts that may need stitches, sore throat or sprains. EMERGENCY ROOM Any condition you believe to be life-threatening. For conditions such as chest pain, deep cuts or wounds, difficulty breathing, poisoning, overdoses and suicidal behavior, abdominal pain, coughing or vomiting blood, severe burns, severe head injuries, sudden loss of balance, vision change, facial droop, and arm or leg weakness. Need help finding a doctor, urgent care, walk-in clinic
or emergency room near you? Use the Provider Search Tool at BSWHealthPlan.com/FindProvider
or call Customer Service at 1.866.334.3141 (TTY: 711). Need help using the Provider Search Tool?
Scan the code to watch a quick instructional video. HMO-POS members may only see in-network specialists without a referral.

4 5 Affordable prescriptions If your plan includes prescription drug benefits, simply present your member ID card at a network pharmacy when you need to fill a prescription. Additional requirements or limits on prescription drug coverage include: Prior authorization: BSW SeniorCare Advantage requires you or your physician to get prior authorization for certain drugs. This means you will need to get approval from the health plan before you fill your prescriptions. Quantity limits: Coverage may be limited to how much medication you can get during a specified period of time, typically based on a 30-day period. Step therapy: This process applies to certain drugs and encourages you to try less costly but equally effective drugs before the plan covers another drug. Access care anytime, anywhere We offer convenient self-service tools so you can get the help you need, 24 hours a day, seven days a week for non-urgent medical conditions, including the flu, sinus infections, bronchitis and more. Virtual care with Teladoc With Teladoc, you can talk to a licensed healthcare provider for non-urgent medical conditions. Confidential therapy is also available. Get help for anxiety, depression, negative thoughts, not feeling like yourself and more. Call 1.800.835.2362 for more information. Conduct an eVisit (online questionnaire) for common medical conditions and get care fast. OR Schedule a same-day Video Visit with a provider, face to face. Visit MyBSWHealth.com OR download the MyBSWHealth app. Google Play is a trademark of Google LLC. Virtual care with MyBSWHealth Using the MyBSWHealth app, you can access your healthcare and health insurance information in one secure portal. Mail order prescriptions Prescriptions can also be conveniently mailed to your home. For a 90-day supply, Tier 1 and Tier 2 prescriptions are available for a $0 copay; Tier 3 prescriptions for two copays rather than three; and Tier 4 is 35% coinsurance (applies to all plans except Essentials). HMO-POS Essentials: Tiers 1-4 25% coinsurance. (See page 15 for details.) You’ll benefit from: ▪ Three-month supplies of your medications ▪ Free standard shipping ▪ Telephone access to pharmacists 24 hours a day, 7 days a week ▪ Helpful reminders to take or refill your medications

6 7 As a valued member of Baylor Scott & White Health Plan, we care about your health and well-being. Whether it’s helping you manage a chronic condition like diabetes, encouraging you to take advantage of your Silver&Fit membership or equipping you with the tools necessary to take control of your health, we are here to give you the resources you need to feel your best.

To help us determine your overall wellness and any health-related needs you may have, go to BSWHealthPlan.com/HRA and complete a brief online questionnaire. When you’re finished, you will be presented with simple and actionable lifestyle and health choices along with online health coaching that will help you achieve your personal health goals.
Have you taken your Health Assessment? Complete your Health Assessment at
BSWHealthPlan.com/HRA Dental insurance policies are underwritten by Metropolitan Life Insurance Company, 200 Park Avenue, New York, NY 10166. Baylor Scott & White Health Plan’s plans include dental benefits through MetLife for no additional premium. Coverage includes things like exams, cleanings, X-rays, extractions and fillings, restorative services and even dentures. Refer to the Evidence of Coverage for complete details, including limitations and exclusions. MetLife’s Preferred Dentist Program is a dental PPO plan. You can visit any licensed dentist—in or out of the MetLife PDP Plus network—and receive benefits. However, if you use an out-of-network provider, your share of the costs for your covered services may be higher. Find a participating dentist at MetLife.com. Dental care Regular eye exams may do more than help maintain your vision. They may also help detect other serious health issues such as diabetes or high blood pressure. Our plans provide coverage for a routine annual exam, plus an annual allowance toward the purchase of contacts, frames and lenses. You can visit any licensed provider, in- or out-of-network, to receive benefits. (PPO plans: Services received from an out-of-network provider will incur an out-of-network coinsurance.) Vision care Hearing care As part of our commitment to helping with our members’ overall quality of life, we offer essential hearing services that are not covered by Original Medicare, including a routine hearing exam and an allowance every three years toward the purchase of hearing aids. You can visit an in-network or out-of-network provider- the choice is yours. (PPO plans: Services received from an out-of-network provider will incur an out-of-network coinsurance.) Refer to the Evidence of Coverage for details. Find a provider at BSWHealthPlan.com/FindProvider. American Academy of Ophthalmology, “20 Surprising Health Problems an Eye Exam
Can Catch,” by Reena Mukamal, April 29, 2022, American Academy of Ophthalmology, aao.org

9 8 Silver&Fit ® Living Boldly™ together 2026 BSW SeniorCare Advantage HMO-POS and PPO plans include a fitness membership at no additional cost. National network of fitness centers Get access to a network of participating fitness centers or select YMCAs. You also have access to Premium locations, including fitness centers, studios and unique fitness experiences, for a buy-up price. Home fitness kits Pick one kit per benefit year from the available options.* Well-being coaching Get support in areas such as fitness, healthy eating, stress, sleep and weight loss while taking GLP-1 or anti-obesity medications. Trained coaches are available by phone, video or chat. On-demand workout videos Visit the Silver&Fit website to find workout videos for all fitness levels. Workout plans Answer a few online questions to get a custom exercise plan that focuses on goals such as getting stronger, staying fit during recovery and chronic condition management. Well-being club Learn new skills and focus on well-being with live virtual classes and events, opportunities to connect in-person, and exclusive articles and videos. FitnessCoach™ virtual personal training Challenge yourself through live
virtual sessions with a certified
personal trainer.* Fitness center participation may vary by location and is subject to change. Fees vary by Premium location. Please refer to the fitness center search on the Silver&Fit website. *Home Fitness Kit promo codes cannot be used in combination with any other promotions on third-party vendor websites. Promo codes will expire at the end of the benefit year. Once selected, kits cannot be exchanged. Kits are based on availability and subject to change. The Silver&Fit program is not a medical provider or pharmacist, and its coaches do not offer medical or pharmaceutical advice. They cannot and do not diagnose or treat medical, mental health, or other health conditions. Coaches provide general information for educational purposes only. For any medical or health concerns, consult a qualified healthcare professional. *Fees and limitations apply. The Silver&Fit program is provided by American Specialty Health Fitness, Inc. (ASH Fitness), a subsidiary of American Specialty Health Incorporated (ASH). Please talk with your doctor before starting or changing your exercise routine. All programs and services are not available in all areas. Persons shown are not Silver&Fit members. Silver&Fit, Living Boldly, FitnessCoach, and the Silver&Fit logo are trademarks of ASH. Other names and logos may be trademarks of their respective owners. Limitations, member fees, and restrictions may apply. Go to SilverandFit.com to get started today! For questions, speak to a Silver&Fit team member toll-free at 1.877.427.4788 (TTY/TDD: 711), Monday – Friday, 7 AM to 8 PM, Central time. Over-the-counter (OTC) allowance BSW SeniorCare Advantage plans feature a quarterly purchase allowance (based on calendar quarter) from participating retailers to purchase eligible OTC items, such as bandages, cold and allergy medicines, pain relievers and more. Members will continue
to use their current card to make purchases.. Participating retailers include: Albertsons, CVS Health, Discount Drug Mart, Dollar General, Family Dollar, HEB, Kroger, Walmart, Walgreens and other independent pharmacy locations. For a full list of participating stores, visit: MyBenefitsCenter.com Note: CVS Pharmacies at Target do not accept OTC Network cards. Unused amounts do not roll over from quarter to
quarter or to next year. HMO-POS plans only In-home meals benefit BSW SeniorCare Advantage HMO-POS plans include a meal benefit to ease your recovery when you return home from
the hospital.

ǵ Fourteen meals per hospital discharge

to home; limited to three discharges
per year.

ǵ Upon being discharged from the hospital,

HMO-POS members receive home- delivered meals at no additional cost. GA Foods will contact you to arrange delivery.

ǵ All meals are low in salt, sugar, fat and

cholesterol, and are suitable for diabetics and those with cardiac conditions. Routine transportation
BSW SeniorCare Advantage HMO-POS plans include routine transportation to approved locations, such as medical appointments, physical therapy visits, labs, grocery stores and drug stores.
To get started, schedule an appointment by contacting Modivcare at 1.866.428.0212. There is no additional cost for this service. It includes up to 24 one-way trips per year, OR 12 round trips up to 50 miles each way. The Modivcare App makes it easy to book a ride for your doctor visit, right from your smartphone or tablet. Just search for the Modivcare App on Google Play® or the Apple App Store®, and download it to book and manage trips. Your OTC card will arrive separately in the mail.

10 11 Care management services If you’re interested in personal assistance related to a disease or chronic condition, our nurse care managers can provide you with free and confidential guidance over the phone. Support includes: ▪ Information to help you better understand and manage your condition or disease; ▪ Personalized answers to your health or medication questions; ▪ Facilitating multiple services such as homecare, medical supplies or

  medical equipment; and

▪ Advice on how to live safely at home. Complex case management If you have chronic conditions or complex care needs, our nurse case managers will work with you, your family and your physician to create and manage your care plan. Case managers advocate for you and can help you navigate the healthcare system and arrange the services you need. They can also answer questions and help you understand your condition and care plan. If you are also enrolled in a disease management program, your case manager will coordinate that program with your complex case management plan. There is no additional cost to you for this voluntary program. It’s all part of our goal to help you get the best possible results and the greatest value from your health plan. Disease management Disease management empowers you to manage your chronic condition and help prevent complications. We work with your healthcare providers to identify chronic conditions quickly and treat them effectively. We can also identify self-care activities that help you manage your condition at home. Together, we’ll work to slow down the progression of your disease and help you stay healthy. To access these care management services, call 1.866.334.3141 (TTY: 711). Kidney health program Members diagnosed with kidney disease may be eligible for a specialized kidney program. This program is included in all BSW SeniorCare Advantage plans and includes many benefits such as: ▪ Personalized approach to managing different medications and diet plans ▪ Help with monitoring your daily vitals CareNav+ is your one-stop resource to help you
navigate your care and coverage. Our care navigators can help you: ▪ Decide what kind of doctor you need, and how quickly ▪ Find the right level of care ▪ Initiate prescription refill requests ▪ Use the MyBSWHealth member portal ▪ Identify obstacles with your care and coordinate solutions ▪ Help schedule and manage your appointments To contact a care navigator, call 1.833.818.1339, Monday - Friday, 8 AM - 5 PM.

12 13 BSW SeniorCare Advantage HMO-POS and PPO Benefits Effective January 1, 2026 This is not a complete description of benefits. Please refer to the plan’s Evidence of Coverage at BSWHealthPlan.com/Medicare. 1If you have Part D (Rx) prescription drug coverage through another carrier, your drug coverage will end when your new BSW SeniorCare Advantage plan starts. Medicare Advantage plans do not allow members to have medical coverage and prescription drug coverage through two different Medicare Advantage plans. (Stand-alone prescription drug plans (PDPs) are considered Medicare Advantage plans.) If you enroll in a BSW SeniorCare Advantage medical plan without prescription drug coverage, you may owe a late enrollment penalty if you try to sign up for prescription drug coverage later. 2Certain plans without Part D (Rx) prescription drug coverage pay toward your Part B premium. This reduction is applied on your Social Security check. For more information, go to ssa.gov.

3To help maximize BSW SeniorCare Advantage PPO benefits, use in-network providers for care; out-of-network cost sharing is 35% for most services and 40% for inpatient hospital. There is a $10,000 out-of-pocket maximum for services received out-of-network. Extra Help, also known as a Low Income Subsidy, is a Medicare program that helps people with limited incomes pay for Medicare drug coverage (Part D) premiums, deductibles, coinsurance and other costs. It also relieves those who qualify from having to pay a Part D late enrollment penalty. In the Essentials plan, if you qualify for Extra Help, your monthly premium is $0 and your covered prescription drugs are $0. If you don’t qualify, you’ll pay a $4.80 monthly premium and 25% of the cost of covered drugs after a $615 deductible. Find out if you qualify for Extra Help: Medicare.gov/basics/costs/help/drug-costs; or Social Security Administration at ssa.gov/medicare/part-d-extra-help Medical Plan Benefits HMO-POS
Select HMO-POS
Select Rx HMO-POS
Essentials PPO3
(In-Network Costs) Monthly Premium (see Part B premium note below) $01 (plan does not include Rx) $0 $0/$4.80 $0 Part B Premium Reduction (for plans without Part D Rx)2 $50 Not available Not available Not available Deductible $0 $0 $0 $0 Out-of-Pocket Maximum $5,550 $5,000 $5,000 $6,400 Annual Physical Exam $0 copay $0 copay $0 copay $0 copay Primary Care Physician (PCP) Office Visit $0 copay $0 copay $0 copay $0 copay Specialty Care Physician (SCP) Office Visit $25 copay $25 copay $20 copay $35 copay Telehealth Visit (PCP, SCP, Psychiatry Services) $0 copay $0 copay $0 copay $0 copay Diagnostic Tests, X-rays, Lab Services (separate office visit copay may apply) Advanced Diagnostic Imaging Services (MRI, MRA, SPECT, CTA) $0 copay $0-$200 copay $0 copay $0-$200 copay $0 copay $0-$200 copay $0 copay $0-$300 copay Physical/Occupational/Speech Therapy (per visit) $35 copay $35 copay $35 copay $35 copay Inpatient Hospital Day 1-6: $225/day per stay Day 7-90: $0/day per stay Day 1-6: $225/day per stay Day 7-90: $0/day per stay Day 1-6: $225/day per stay Day 7-90: $0/day per stay Day 1-6: $320/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 Day 1-5: $318/day per stay Day 6-90: $0/day per stay Day 1-5: $318/day per stay Day 6-90: $0/day per stay 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 Day 1-20: $0/day Day 21-100: $218/day Day 1-20: $0/day Day 21-100: $218/day Day 1-20: $0/day Day 21-100: $218/day Outpatient Surgery (facility) $275 copay $275 copay $275 copay $350 copay Ambulatory Surgical Center (facility) $250 copay $250 copay $250 copay $275 copay Ambulance $265 copay $300 copay $300 copay $325 copay Emergency Care (within the U.S.; copay waived if admitted within 24 hours) $130 copay $130 copay $130 copay $130 copay Urgent Care (within the U.S.; copay waived if admitted within 24 hours) $50 copay $50 copay $50 copay $50 copay Worldwide Emergency/Urgent Services (outside the U.S.) $0 copay $5,000 maximum $0 copay $5,000 maximum $0 copay $5,000 maximum $0 copay $5,000 maximum Durable Medical Equipment (DME) 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance Podiatry $40 copay $40 copay $40 copay $45 copay Chemotherapy Drugs 0%-20% coinsurance 0%-20% coinsurance 0%-20% coinsurance 0%-20% coinsurance Other Part B Drugs 0%-20% coinsurance 0%-20% coinsurance 0%-20% coinsurance 0%-20% coinsurance

14 15 BSW SeniorCare Advantage HMO-POS and PPO Benefits
Effective January 1, 2026 Dental Benefits for All Plans Monthly Premium Included Deductible $0 Oral Exams (one every 6 months) $0 Cleanings (one every 6 months) $0 Dental X-rays $0 Extractions
50% coinsurance Dental Benefits That Vary by Plan Annual Dental Benefit Maximum $3,000 $3,500 $3,000 $3,500 Dentures (every 5 years) 50% coinsurance $0 copay 50% coinsurance $0 copay Fillings (one filling per surface, per tooth every 24 months) 50% coinsurance 0% - 50% coinsurance 50% coinsurance 0% - 50% coinsurance Restorative Services 50% coinsurance 0% - 50% coinsurance 50% coinsurance 0% - 50% coinsurance Extra Help, also known as a Low Income Subsidy, is a Medicare program that helps people with limited incomes pay for Medicare drug coverage (Part D) premiums, deductibles, coinsurance and other costs. It also relieves those who qualify from having to pay a Part D late enrollment penalty. In the Essentials plan, if you qualify for Extra Help, your prescription copays range from $0 to $5.10 for generic drugs and $0 to $12.65 for all other drugs, based your Low Income Subsidy level and your monthly premium will be $0. If you don’t qualify, you’ll pay 25% of the cost of covered drugs after a $615 deductible, and your monthly premium will be $4.80. Find out if you qualify: Medicare.gov/basics/costs/help/drug-costs; OR Social Security Administration at ssa.gov/medicare/part-d-extra-help HMO-POS Essentials $0 premium and prescriptions Prescription Drug Benefits Applies to plans with Part D (Rx) only HMO-POS
Select HMO-POS
Select Rx HMO-POS
Essentials PPO
(In-Network Costs) Deductible Not available $250 (applies to Tiers 3-5) $615 $300 (applies to Tiers 3-5) Total Out-of-Pocket Amount Not available $2,100 $2,100 $2,100 Retail Copays During Initial Coverage Period (30-day supply) Preferred/Standard Pharmacy

     Tier 1 – Preferred Generic Drugs

Not available $0/$10 copay 25% coinsurance* $0/$5 copay

     Tier 2 – Generic Drugs

Not available $13/$20 copay 25% coinsurance* $7/$14 copay

     Tier 3 – Preferred Brand Drugs

Not available $47/$47 copay 25% coinsurance* $47/$47 copay

     Tier 4 – Non-Preferred Drugs

Not available 35% coinsurance 25% coinsurance* 35% coinsurance

     Tier 5 – Specialty Drugs

Not available 30% coinsurance 25% coinsurance* 29% coinsurance Mail Order Copays (90-day supply)

                                                                                    Tiers 1-2 are $0 copay; Tier 3 is two copays; and Tier 4 is 35% coinsurance (applies to all plans except Essentials)
                                                                                         HMO-POS Essentials: Tiers 1-4 25% coinsurance*

Catastrophic Coverage Amounts − You Pay Not available $0 copay $0 copay $0 copay Even if you haven’t paid your deductible, you won’t pay more than $35 for a one-month supply of each covered insulin product regardless of the cost-sharing tier and no cost for most adult Part D vaccines.

16 BSW SeniorCare Advantage HMO-POS and PPO Benefits Effective January 1, 2026 Supplemental Benefits HMO-POS
Select HMO-POS
Select Rx HMO-POS
Essentials PPO
(In-Network Costs) Routine Eye Exam (one per year) $0 copay $0 copay $0 copay $0 copay Eyewear (annually) $125 allowance $200 allowance $130 allowance $150 allowance Routine Hearing Exam (one per year) $0 copay $0 copay $0 copay $0 copay Hearing Aids (every 3 years) $1,000 allowance $1,200 allowance $1,000 allowance $1,100 allowance Fitness Membership (home fitness programs, activity tracker, and/or gym/ fitness club membership at participating locations) $0 $0 $0 $0 Over-the-counter (OTC) Allowance (must use OTC Network card at participating retailers; no rollover) $30 per quarter $100 per quarter $100 per quarter

$80 per quarter In-Home Meals (14 meals per hospital discharge to home; limit 3 discharges per year) $0 copay $0 copay $0 copay Not available Routine Transportation (up to 24 one-way trips per year, or 12 round trips
up to 50 miles each way) $0 copay $0 copay $0 copay Not available Camero Cameron North Texas Coverage Area The counties in the North Texas HMO-POS and PPO service area are: Collin, Dallas, Denton, Ellis, Johnson, Rockwall, Tarrant

2026 Benefits of Membership Important BSW SeniorCare Advantage Information 1206 West Campus Drive Temple, TX 76502