Plan Documents | Baylor Scott & White Health Plan

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Member Plan Documents: As a member, you can view your specific Plan Documents in the Member Portal quickly and easily.

Standard Individual & Family Marketplace, Small Group and Large Group Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) documents are available in PDF file format for download here.

Custom plan documents are not included in this directory as they can be accessed on the employer's BSWHP sub-site and also from the Member Portal. All plan documents, including custom plan documents, can be found in the Member Portal. After logging in, you will only see the plan documents that apply to you.

Browse by Plan

Primary Care Physician (PCP) referrals are not required for any of our plans.

Need help?

Contact Support at 844.633.5325 (TTY: 711).

Other Year's Documents

2024 Plan Documents

Summary of Benefits and Coverage (SBC)

Individual - Gold Plans (SBC)

BSW Elite Gold HMO 001
BSW Elite Gold HMO 001
BSW Elite Gold HMO 001 - Native American Zero
BSW Elite Gold HMO 001 - Native American Limited
BSW Elite Gold HMO 002
BSW Elite Gold HMO 004
BSW Elite Gold HMO 004
BSW Elite Gold HMO 004 - Native American Zero
BSW Elite Gold HMO 004 - Native American Limited
BSW Elite Gold HMO 012
BSW Elite Gold HMO 012
BSW Elite Gold HMO 012- Native American Zero
BSW Elite Gold HMO 012 - Native American Limited

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Individual - Silver Plans (SBC)

BSW Prime Silver HMO 003
BSW Prime Silver HMO 003
BSW Prime Silver HMO 003 - Native American Zero
BSW Prime Silver HMO 003 - Native American Limited
BSW Prime Silver HMO 003 - CSR 73% AV
BSW Prime Silver HMO 003 - CSR 87% AV
BSW Prime Silver HMO 003 - CSR 94% AV
BSW Prime Silver HMO 005
BSW Prime Silver HMO 005
BSW Prime Silver HMO 005 - Native American Zero
BSW Prime Silver HMO 005 - Native American Limited
BSW Prime Silver HMO 005 - CSR 73% AV
BSW Prime Silver HMO 005 - CSR 87% AV
BSW Prime Silver HMO 005 - CSR 94% AV
BSW Prime Silver HMO 008
BSW Prime Silver HMO 008
BSW Prime Silver HMO 008 - Native American Zero
BSW Prime Silver HMO 008 - Native American Limited
BSW Prime Silver HMO 008 - CSR 73% AV
BSW Prime Silver HMO 008 - CSR 87% AV
BSW Prime Silver HMO 008 - CSR 94% AV
BSW Prime Silver HMO 010
BSW Prime Silver HMO 011

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Individual - Bronze Plans (SBC)

BSW Savers Bronze HMO H S A 006
BSW Savers Bronze HMO H S A 006
BSW Savers Bronze HMO 006 - Native American Zero
BSW Savers Bronze HMO H S A 006 - Native American Limited
BSW Vital Bronze EPO 001
BSW Vital Bronze HMO 001
BSW Vital Bronze HMO 007
BSW Vital Bronze HMO 007
BSW Vital Bronze HMO 007 - Native American Zero
BSW Vital Bronze HMO 007 - Native American Limited
BSW Vital Bronze HMO 009
BSW Vital Bronze HMO 009
BSW Vital Bronze HMO 009 - Native American Zero
BSW Vital Bronze HMO 009 - Native American Limited

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Small Group - Gold Plans (SBC)

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Small Group - Silver Plans (SBC)

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Small Group - Bronze Plans (SBC)

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Large Group SBC Documents

Plans are identified by coinsurance/individual deductible/individual maximum out-of-pocket/PCP copay/Specialist copay. Prescription drug riders and networks are also listed for each plan.

Large Group - HMO Plans (SBC)

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Large Group - POS Plans (SBC)

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Large Group - PPO Plans (SBC)

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Large Group - Out-of-Area Network Plans (SBC)

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Evidence of Coverage (EOC)

Individual - Gold Plans (EOC)

BSW Elite Gold HMO 001
BSW Elite Gold HMO 001
BSW Elite Gold HMO 001 - Native American Zero
BSW Elite Gold HMO 001 - Native American Limited
BSW Elite Gold HMO 002
BSW Elite Gold HMO 004
BSW Elite Gold HMO 004
BSW Elite Gold HMO 004 - Native American Zero
BSW Elite Gold HMO 004 - Native American Limited
BSW Elite Gold HMO 012
BSW Elite Gold HMO 012
BSW Elite Gold HMO 012- Native American Zero
BSW Elite Gold HMO 012 - Native American Limited

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Individual - Silver Plans (EOC)

BSW Prime Silver HMO 008
BSW Prime Silver HMO 008
BSW Prime Silver HMO 008 - Native American Zero
BSW Prime Silver HMO 008 - Native American Limited
BSW Prime Silver HMO 008 - CSR 73% AV
BSW Prime Silver HMO 008 - CSR 87% AV
BSW Prime Silver HMO 008 - CSR 94% AV
BSW Prime Silver HMO 003
BSW Prime Silver HMO 003
BSW Prime Silver HMO 003 - Native American Zero
BSW Prime Silver HMO 003 - Native American Limited
BSW Prime Silver HMO 003 - CSR 73% AV
BSW Prime Silver HMO 003 - CSR 87% AV
BSW Prime Silver HMO 003 - CSR 94% AV
BSW Prime Silver HMO 005
BSW Prime Silver HMO 005
BSW Prime Silver HMO 005 - Native American Zero
BSW Prime Silver HMO 005 - Native American Limited
BSW Prime Silver HMO 005 - CSR 73% AV
BSW Prime Silver HMO 005 - CSR 87% AV
BSW Prime Silver HMO 005 - CSR 94% AV
BSW Prime Silver HMO 010
BSW Prime Silver HMO 011

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Individual - Bronze Plans (EOC)

BSW Savers Bronze HMO H S A 006
BSW Savers Bronze HMO H S A 006
BSW Savers Bronze HMO 006 - Native American Zero
BSW Savers Bronze HMO H S A 006 - Native American Limited
BSW Vital Bronze HMO 001
BSW Vital Bronze EPO 001
BSW Vital Bronze HMO 007
BSW Vital Bronze HMO 007
BSW Vital Bronze HMO 007 - Native American Zero
BSW Vital Bronze HMO 007 - Native American Limited
BSW Vital Bronze HMO 009
BSW Vital Bronze HMO 009
BSW Vital Bronze HMO 009 - Native American Zero
BSW Vital Bronze HMO 009 - Native American Limited

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Small Group - Gold Plans (EOC)

Coming soon...

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Small Group - Silver Plans (EOC)

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Small Group - Bronze Plans (EOC)

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Large Group EOC Documents

Plans are identified by coinsurance/individual deductible/individual maximum out-of-pocket/PCP copay/Specialist copay. Prescription drug riders and networks are also listed for each plan.

Large Group - HMO Plans (EOC)

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Large Group - POS Plans (EOC)

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Large Group - PPO Plans (EOC)

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Large Group - Out-of-Area Network Plans (EOC)

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MyPlan PPO Transitional

Summary of Benefits and Coverage

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Evidence of Coverage

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Small Group POS Transitional

Summary of Benefits and Coverage

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Evidence of Coverage

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Plan Descriptions

Individual

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Small Group

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Large Group

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EPO Outline of Coverage

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PPO Disclosures

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