Skip to main content Skip to footer
 
 

Covenant Health Advantage HMO

Plan Documents and Resources

2023 Covenant Health Advantage HMO plans

Members can get personalized plan information by logging into the Member Portal (available 1/1/2023). Once enrolled in the plan, you can quickly register for Member Portal access. Visit Member Resources for more information.

West Texas


Plan Directories and Search Tools

*The Pharmacy Search Tool can be used to locate additional in-network pharmacies.

Request a Printed Directory: Want a paper version? You can have printed plan documents mailed to your home.

  • Members can make this request by logging in to the Member Portal (available 1/1/2023).
  • Non-Members can request by calling 833.442.2405 (TTY: 711) 7 AM to 8 PM CT, daily.

Evidence of Coverage

West Texas HMO

 

Member Resources

For Covenant Health Advantage Members

Access Your Health Information

Member Portal

Using the member portal, you can access your health insurance information 24 hours a day, seven days a week.

Quick Links


Health and Wellness Programs

Treating yourself right isn't a trend. It's a good habit. And it's a habit anyone can pick up. Take advantage these programs to help you improve the areas of your life that need a boost.

More Resources

Your MetLife dental benefits start here

Dental coverage is provided by Metropolitan Life Insurance Company, New York, New York (MetLife).

Dental plans

Dental Benefits Covenant Health Advantage HMO Covenant Health Advantage HMO Rx
Monthly Premium Included Included
Yearly Benefit Maximum $2,500 $2,500
Deductible $0 $0
Oral Exams
(every 6 months)
$0 $0
Dental X-rays
(every 3 years)
$0 $0
Extractions and Fillings 50% 50%
Dentures
(every 5 years)
50% 50%

Looking for dental providers in your area? We can help.

MetLife's Preferred Dentist Program is a dental PPO plan that gives you more choices. You can visit any licensed dentist — in or out of the MetLife PDP Plus network — and receive benefits.

Get information about your account

Log into the MetLife MyBenefits portal to verify your eligibility, find your summary of benefits, check claims status and more. Or call 855.676.9337 and speak with a MetLife customer service agent to get the answers you need.

View your Evidence of Coverage (EOC)

These booklets, accessible from your MetLife MyBenefits portal or by logging into the Member Portal, give you the details about your MetLife dental coverage from Jan. 1 through Dec. 31.

Covenant Health Advantage HMO plans include a fitness membership with Silver&Fit at no additional cost to members:

  • 8,000+ digital workout videos
  • Home fitness kits
  • Access to one of 16,500+ participating fitness centers
  • Daily workout videos
  • Healthy aging coaching

How-To Video: Get Started Workout Plans

ModivCare

(Routine transportation benefits for HMO plans)

Covenant Health Advantage HMO 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 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.

866.428.0212
ModivCare.com

Cricket Health

(kidney health program)

Members who are living with or at risk for developing kidney disease may be eligible for Cricket Health, a kidney support service. It's available to Covenant Health Advantage Plan members at no extra cost and supports your health needs between visits with your doctors.

You'll have access to:

  • A dedicated team, including a nurse, pharmacist, nutrition coach and more, by phone or online
  • A peer mentor and others on a similar health journey
  • Information on demand that helps you understand your health

...all from the comfort of your home!

To find out if you're eligible
888.780.0253
CricketHealth.com/eligible

Landmark Health

(in-home acute care program)

Members with multiple chronic conditions may be eligible for care in to the home through in-home medical visits by doctors and other providers.

  • Routine and urgent house calls and 24/7 phone support
  • Prescribing and reviewing medications
  • In-home labs and interventions
  • Behavioral health, nutrition and social work support

877.260.9992
LandmarkHealth.org

InComm

(Over-the-counter [OTC] benefits for HMO plans)

Covenant Health Advantage HMO plans feature a quarterly allowance from participating retailers to purchase eligible over-the-counter items such as bandages, cold and allergy medicines, pain relievers and more. You will receive a mailing for the OTC Network with a card and instructions for setting up an account to view available items and for making purchases. Participating retailers include: CVS, Discount Drug Mart, Dollar General, Family Dollar, HEB, Rite Aid, Walmart, Walgreens and other independent pharmacy locations.

Note: CVS Pharmacies at Target do not accept OTC Network cards. Unused amounts do not roll over from quarter to quarter or to the next year.

833.442.2405
MyOTCCard.com

Plan ahead for peace of mind.

Sometimes a serious illness or injury can leave a patient unable to communicate, and families have the burden of making difficult decisions without knowing what their loved one really wants. An advance care plan lets you make your medical wishes known ahead of time.

If you have low income and few resources, you may qualify for up to $4,000 in subsidies to apply toward your Medicare payments. Subsidy amounts vary. See if you qualify for Extra Help with these resources.

As a Medicare member, you have the right to:

  • Ask for coverage of a medical service or prescription drug. In some cases, we may allow exceptions for a service or drug that is normally not covered.
  • File an appeal if your request is denied. An appeal is a formal way of asking us to review and change a coverage decision we made.

You can submit your request for medical service coverage or appeal to the following:

Mail:

Baylor Scott & White Health Plan
1206 W. Campus Drive
Temple, TX 76502

Fax:

800.626.3042

Phone:

833.442.2405 (TTY: 711)

You can submit a request for Part D drug coverage or redetermination (appeal). Visit Drug Requests - Prior Authorizations, Exceptions and Appeals for more details

Addressing your concerns and resolving them promptly is important to us, because it's important to you. As a member of Baylor Scott & White Health Plan (BSWHP), you have the right to request an appeal and file a grievance.

Appeal

An appeal is a request for reconsideration of our determination on a service, supply or drug you have received or requested. You may file an appeal when you believe that the services or supplies should be covered or that they should be covered differently than Baylor Scott & White Health Plan approved or paid them. Your doctor can also request an appeal for you.

Grievance

A grievance is a complaint that does not involve a coverage determination. For example, grievances may be filed if you are unhappy with the quality of care or service you receive from us or from our Baylor Scott & White Health Plan network providers. You also have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug.

We encourage your input and will not discriminate against you, refuse coverage or engage in any other retaliation if you choose to file a complaint or request an appeal of a decision.

Additionally, we're prohibited from retaliating against a physician or provider who has filed a complaint against us on your behalf. You may also refer to your Evidence of Coverage for complaint examples and complete details.

For status or process questions or to obtain an aggregate number of grievances and appeals, please call Customer Service at 833.442.2405, 7 AM to 8 PM daily; or write:

Baylor Scott & White Health Plan
1206 W. Campus Drive
Temple, TX 76502
Fax: 800.626.3042

You can also submit an appeal and grievance to Medicare:

Voluntary disenrollment

If you are considering disenrollment, please call our Member Advocacy Department at 833.442.2405 (TTY: 711). We want to help you in any way we can. Our Member Advocates can help you resolve problems before you make the final decision to change health plans.

Medicare gives you two ways you can disenroll from a Medicare Advantage plan:

  • Annual Election Period (AEP), Oct. 15-Dec. 7
  • Special Election Period (SEP)

If your situation includes the following, you can enter a Special Enrollment Period:

  • You move outside our service area, or have experienced another change in circumstances — as determined by the Centers for Medicare & Medicaid Services (CMS) — that causes you to no longer be enrolled in a BSW SeniorCare plan
  • You're entitled to Medicare Part A and Part B and receive any type of assistance from the Title XIX (Medicaid) program
  • CMS or the organization has terminated our contract in the area in which you reside, or the organization has notified you of the impending termination or discontinuation of the plan in the area you reside
  • You demonstrate that we have substantially violated a material provision of our contract with CMS in relation to you, or we (or an agent) materially misrepresented the plan when marketing our plans
  • You weren't adequately informed of the creditable status of drug coverage provided by an entity required to give such notice, or a loss of creditable coverage. CMS determines eligibility for this on a case by case basis
  • Your enrollment or non-enrollment is erroneous due to an action, inaction or error by a federal employee
  • You meet such other exceptional conditions as CMS may provide

Ways to disenroll during AEP, MADP or valid Special Enrollment Period:

  • Call us at 833.442.2405 (TTY: 711)
  • Call 800.MEDICARE
  • Deliver, mail or fax a signed and dated written notice to the plan
  • Enroll in another plan during a valid enrollment period, which will prompt disenrollment in your current plan. Use your current plan until disenrollment is effective

Involuntary disenrollment

We may disenroll you if:

  • Premiums are not paid on a timely basis
  • You engage in disruptive behavior
  • You provide fraudulent information on an enrollment request
  • You permit abuse of an enrollment card

If we choose to terminate your coverage for any of these reasons, we'll send you notice of the upcoming disenrollment. This notice will:

  • Advise you we plan to disenroll you, and why such action is occurring
  • Provide the effective date of termination
  • Include an explanation of your right to a hearing under our grievance procedures

Required involuntary disenrollment

We are required to disenroll you if:

  • A permanent change in residence makes you ineligible to be an enrollee of our advantage plans
  • You lose entitlement to Medicare
  • We are notified of your passing
  • Our contract is terminated, or we discontinue offering a Prescription Drug Plan in the area where it had previously been available*
  • You materially misrepresent information to us regarding reimbursement for third-party coverage

*Authorized by law to refuse to renew its contract with CMS. In addition, CMS also may refuse to renew the contract, and that termination or non-renewal may result in termination of your enrollment.

Pharmacy and Drugs

  • *The Pharmacy Search Tool can be used to locate additional in-network pharmacies.

What is Quality Assurance?

This is a sign of our dedication to providing quality healthcare. Quality assurance includes measures and systems to reduce medication errors and adverse drug interactions, and improve medication use.

Examples of quality assurance processes in relation to Medicare Part D may include the following:

Concurrent Drug Utilization Review

This occurs when a prescription is being filled at the pharmacy. Your prescriptions are reviewed for safety issues that may address the following:

  • Possible medication errors
  • Drug dosage and therapy duration errors
  • Duplicate drugs that are unnecessary because you are taking another to treat the same medical condition
  • Drug allergies
  • Possible harmful interactions between the drugs you are taking
  • Drugs that are not appropriate for your age or gender

Retrospective Drug Utilization Review

This occurs after a prescription is filled. This process reviews members' drug histories and identifies opportunities to improve the quality of care by identifying patterns of inappropriate or medically unnecessary therapy.

What Is Drug Utilization Management?

Drug utilization management programs are designed to improve quality and reduce costs when medically appropriate. The program includes systems to assist in preventing overuse and underuse of prescribed medications.

Examples of utilization management in relation to Medicare Part D may include the following:

Prior Authorizations & Exceptions

We require you to get prior authorization for certain drugs on formulary. This means you will need to get approval from our Pharmacy Benefit Manager (PBM), OptumRx, before you fill prescriptions for these drugs. If you do not get approval, Baylor Scott & White Health Plan may not cover the drug. Additionally, to request coverage for a drug not listed on formulary, an exception request must be submitted to the PBM.

Quantity Limits

For certain drugs, there are limits to the amount of the drug that we will cover. For example, we provide up to a certain number of tablets per prescription for a certain drug.

Step Therapy

In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Baylor Scott & White Health Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Baylor Scott & White Health Plan will then cover Drug B.

Use of Generic Drugs

We cover both name brand and generic drugs. A generic drug has the same active ingredient as the name brand drug. Generic drugs usually cost less than name brand drugs and are approved by the Food and Drug Administration (FDA).

As a new or continuing member, you might be taking drugs that are not on our formulary or taking a drug that requires you to meet certain requirements, like preauthorization, step therapy or quantity limits.

If you're in the first 90 days of coverage for this plan year, we'll cover a temporary 30-day supply of your drug at any in-network pharmacy to give you time for you and your doctor to plan your future treatment. If you're at a long-term care facility, we will cover a temporary 31-day supply of your drug at any in-network pharmacy.

Talk to your doctor about whether you should switch to a drug on our formulary or request an exception to see if we can cover the drug you're taking. You can view our full Medicare Part D Transition Policy to learn more. If you need assistance requesting an exception or have questions about the transition process, contact us.

Drug Coverage Requests and Appeals

Information about how to submit a request for prescription drug coverage or request an appeal.

Texas-Sized Customer Service

Have questions, or want a little extra assistance?

Give us a call at 833.442.2405 (TTY: 711) 7 AM to 8 PM CT, daily.

Baylor Scott & White Health Plan
1206 W. Campus Drive
Temple, TX 76502

customer service

Baylor Scott & White Health Plan offers BSW SeniorCare AdvantageTM HMO plans as a Medicare Advantage (MA) organization through a contract with Medicare. Baylor Scott & White Care Plan offers Covenant Health Advantage HMO plans as an MA organization through a contract with Medicare. Baylor Scott & White Insurance Company offers BSW SeniorCare AdvantageTM 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.

Y0058_BSWHPWEBSITE2023_A CMS Approved 10/01/2022 | Last updated: 10/01/22

Scroll To Top