Be Well™ with Diabetes

Program Description

The BSW Be Well™ with Diabetes program ("Program") is a voluntary wellness program offered by Scott and White Care Plans d/b/a Baylor Scott & White Care Plan ("BSWCP") and Baylor Scott & White Insurance Company ("BSWIC") that seeks to help improve the health of our members with Type 2 Diabetes. The goal of the Program is to assist eligible members in managing their diabetes and help them reduce diabetes-related complications (such as eye disease, kidney disease, and heart disease) through education and personalized coaching.

A member who is accepted in the Program will be eligible to receive a reward in the form of a copayment waiver of their covered prescription diabetes drugs and supplies ("Reward") as of the start date of the Program.

The Program will continue for 12 months, as long as participation requirements are met. A new application must be submitted for consideration after that time for subsequent participation and an additional period of Reward.

Program requirements follow the American Diabetes Association and American Association of Clinical Endocrinologists guidelines for excellent care of Type 2 Diabetes.

ELIGIBILITY

You may be eligible to participate in this program if you...

• are a member of Baylor Scott & White Care Plan or Baylor Scott & White Insurance Company,
• are not currently enrolled in an HSA eligible High Deductible Health Plan
• have Type 2 Diabetes,
• are 18 years of age or older,
• submit all required information (see below) and
• agree to comply with the program requirements.

SUBMIT A COMPLETED APPLICATION AND ALL REQUESTED INFORMATION

Provide us with the following information:

1. Completely fill out the below "Wellness Application."
2. Provide information about required initial health activities, including:
   • Wellness screening, including lab tests: Hemoglobin A1c, lipid panel/cholesterol and urine test for protein.
   • Recent provider visit (primary care provider (PCP) or endocrinologist).

Initial health activities must be completed or scheduled within the last 12 months prior to the Program start date as listed in the table below. Note: Scheduled appointments after the program start date need to be completed within the first two months.

You are encouraged to share your results or any health concerns with your provider. A pharmacist will review your medication list and communicate any concerns to your provider.

PROGRAM REQUIREMENTS ONCE ENROLLED

You must complete all the following health activities to remain in the Program and continue to receive Rewards.

• Annual lab test: Complete the wellness screening lab tests annually (Hemoglobin A1c, Lipid panel/Cholesterol and Urine test for protein)
• Annual provider visit: Complete an annual visit to the provider treating you for your Type 2 Diabetes
• Wellness coaching: Complete eight (8) coaching sessions with a wellness coach (BSW Be Well™ Coaching) over the course of nine (9) months. Additional details follow.

YOUR ACTIVE PARTICIPATION KEEPS YOU ENROLLED IN THE PROGRAM

Once enrolled in the Program, you will need to complete eight (8) health coaching sessions provided by BSW Be Well™ Coaching ("Wellness Coaching"). Active participation (defined as 1 completed visit) in wellness coaching, BSW Be Well™ Coaching, is required within your first two (2) months of the Program. Wellness coaching will be provided virtually. If you are dismissed from BSW Be Well Coaching for 3 consecutive no call-no shows, you will be dismissed from BSW Be Well with Diabetes as well.

Failure to meet all requirements of the Program will result in dismissal from the Program for the remainder of your enrollment period. Dismissal from the Program will occur 30 days after written notification is sent from BSWCP or BSWIC, which may be sent to the member's home address on record with BSWCP or BSWIC by U.S. mail or email. If you are dismissed from the Program, you will no longer be eligible to receive the copayment waiver for future prescription diabetes drugs and supplies under your pharmacy benefit for the existing 12-month enrollment period. Once a termination notice is sent, reinstatement to the Program is not allowed for any reason for the remainder of the existing 12-month enrollment period. If you have been previously dismissed from the program 2 times, you will no longer be eligible to apply for the Program for any reason.

If you are unable to participate in activities required to receive the Reward, you may be entitled to a reasonable accommodation or an alternative standard. Please contact us as soon as possible. You may request a reasonable accommodation or an alternative standard by contacting BSWHP Pharmacy Customer Service at 800.728.7947 or email BSWHPDiabetesProgram@BSWHealth.org. Recommendations from your provider will try to be accommodated.

Program Application and Start Dates

PROGRAM RESTRICTIONS

Waiver of copayment is limited to prescription diabetes drugs and supplies that are FDA-approved for the treatment of Type 2 Diabetes and are covered under the member's pharmacy benefit. The member's share-of-cost continues to apply for all other covered services and supplies, including diabetes-related services not covered through your pharmacy benefit.

Requirements for receiving covered prescription medications (such as prior authorization) and limitations and exclusions for your benefit plan (such as prescription quantity limits, and step therapy) continue to apply. (Refer to your drug formulary located on our Pharmacy page)

Waiver of your copayment under this Program shall apply to your annual out-of-pocket maximum as defined by your benefit plan.

The Reward is not applicable to items or services that are not covered under the member's pharmacy benefit or benefit plan. This means that you are responsible for any and all copayment, cost share or other cost associated for items or services obtained outside of the pharmacy benefit, such as visits to your provider.

You will need to complete a new application and required health activities for each year you want to participate in the Program and to qualify for another period of Reward.

Participation in the Program and the Reward automatically terminates if your current plan coverage ends (for any reason). BSWCHP or BSWIC reserve the right to terminate a member from this Program for non-compliance with program requirements with a 30-day notice, at which time Rewards will also terminate as of the effective date of termination.

QUESTIONS

Do you have questions about this Program? Refer to our FAQ, visit BSWHealthPlan.com/BeWell-Diabetes, call us at 800.728.7947 or send an email to: BSWHPDiabetesProgram@BSWHealth.org

Terms and Conditions

I, the undersigned, request Baylor Scott & White Care Plan ("BSWCP") or Baylor Scott & White Insurance Company ("BSWIC") to consider my participation in its Type 2 Diabetes Program (the "Program"). If accepted for participation, I understand and agree as follows:

1. I acknowledge that I have received, read, and understood the description of the Program and Program participation requirements. I understand participation in the Program requires my fulfillment of these requirements.
2. I understand that I must be a member of BSWCP or BSWIC through an eligible employer's benefit plan, meet eligibility requirements and be accepted in the Program to receive the copayment waiver ("Reward"), as detailed in the Program Description.
3. I understand that participation in the Program is voluntary, and I may withdraw at any time upon notification to BSWHP via email at BSWHPDiabetesProgram@BSWHealth.org.
4. I understand that participation in the Program will expire upon my loss of eligibility for coverage and/or termination of my health plan contract. In addition, I understand that failure to meet the Program requirements will result in termination from the Program. Upon the effective date of termination, any waiver of copayments for eligible covered prescription medications and supplies for my Type 2 Diabetes will terminate, and the applicable copayment for my benefit plan will apply to any future prescription fills.
5. I understand that if I am unable to participate in the required activities to receive the copayment waiver, I may be entitled to a reasonable accommodation or alternative standard. To request reasonable accommodation or alternative, I am required to contact BSWHP Pharmacy Customer Service at 800.728.7947 or email BSWHPDiabetesProgram@BSWHealth.org as soon as possible.
6. I understand that participation in, or recommendations through, the Program will not replace any care plan designed by me and my provider.
7. I understand if I have concerns or would like to file a complaint, I can do so by reaching BSWCP or BSWIC at 844.633.5325. Please refer to your plan documents for additional information.
8. I understand that the information provided on this form is protected by law and is subject to Baylor Scott and White Health's notice of privacy practices.