Thank you for your interest in the BSW Be Well™ with Diabetes program. Please fill out this form completely; your information will be reviewed to see if you qualify. You will be notified if any additional information is needed and whether or not you have been enrolled into the pilot program.
The BSW Be Well™ with Diabetes program ("Program") is a voluntary wellness program offered by Baylor Scott and White Care Plans ("BSWCP") 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.
You may be eligible to participate in this program if you...
Provide us with the following information:
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 will be accepted.
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.
You must complete all of the following health activities to remain in the Program and continue to receive Rewards.
Once enrolled in the Program, you will need to complete ten (10) 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 6 months of the Program. Wellness coaching will be provided virtually via the Healthie Inc. app or website, GetHealthie.com. If you are unable to access Healthie, please contact BSWCP Pharmacy Customer Service at 800.728.7947 to discuss alternative options.
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, which may be sent to the member's home address on record with BSWCP by U.S. mail or by 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.
*You may submit an application up to Dec. 31; however, if you are accepted into the Program, copayment waivers may not be effective until your actual program start date.
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 reserves the right to terminate this Program at any time with a 30-day notice to all participants, at which time Rewards will also terminate as of the effective date of termination.
Do you have questions about this Program? Refer to the FAQ on our website, BSWHealthPlan,com/BeWell-Diabetes, call us at 800.728.7947 or send an email to: BSWHPDiabetesProgram@BSWHealth.org
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Please complete the Wellness Screening information requested below. Once BSWCP receives the information, we will inform you if we require additional information or confirm you have been accepted in the Program.
If your provider visit and/or lab work are done in a Baylor Scott & White Health clinic or facility, your results will be available to us automatically. However, if you enter this information below, it will expedite your enrollment. If you do not have this information available, please skip to the Current Medication List to continue your application.
If your provider visit and lab work are NOT done in a Baylor Scott & White Health clinic or facility, you are required to have your provider fax your lab results and documentation of your visit to 254.298.6187 or email to BSWHPDiabetesProgram@BSWHealth.org.
Initial health activities must be completed or scheduled within the last 12 months prior to the Program start date. Note: scheduled appointments after the program start date will be accepted.
I, the undersigned, request Baylor Scott & White Care Plan ("BSWCP") to consider my participation in its Type 2 Diabetes Program (the "Program"). If accepted for participation, I understand and agree as follows:
I am entering my name in the Signature field that follows with the intent that this serve as my signature to this Pilot Plan application form.
You must agree to the Terms and Conditions in order to complete and submit the application.
Thank you for your interest in BSW Be Well™ with Diabetes. Your application will be reviewed and we will let you know by email if you qualify.
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