2025 Plan Documents for Members

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)

• Gold PPO 90 4500 BSW Plus PPO
• Gold PPO 100 4000 BSW Plus PPO
• Gold PPO 100 3500 BSW Plus PPO
• Gold PPO HSA 3700 BSW Plus PPO
• Gold PPO 100 3000 BSW Plus PPO
• Gold PPO 80 3000 BSW Plus PPO
• Gold PPO HSA 3200 BSW Plus PPO
• Gold PPO 100 2300 BSW Plus PPO
• Gold PPO 90 2000 BSW Plus PPO
• Gold PPO 90 1800 BSW Plus PPO
• Gold PPO 80 1500 BSW Plus PPO
• Gold PPO 80 1000 BSW Plus PPO
• Gold PPO 80 750 BSW Plus PPO
• Gold PPO copayment 0 7000 BSW Plus PPO
• Gold HMO 90 4500 BSW Premier HMO
• Gold HMO 100 4000 BSW Premier HMO
• Gold HMO 100 3500 BSW Premier HMO
• Gold HMO HSA 3700 BSW Premier HMO
• Gold HMO 100 3000 BSW Premier HMO
• Gold HMO HSA 3200 BSW Premier HMO
• Gold HMO 100 2300 BSW Premier HMO
• Gold HMO 90 2000 BSW Premier HMO
• Gold HMO 90 1800 BSW Premier HMO
• Gold HMO 80 1500 BSW Premier HMO
• Gold HMO 80 1000 BSW Premier HMO
• Gold HMO 80 750 BSW Premier HMO
• Gold HMO copayment 0 7000 BSW Premier HMO
• Gold HMO SM 0 9200 BSW Premier HMO
• Gold HMO 90 4500 BSW Plus HMO
• Gold HMO 100 4000 BSW Plus HMO
• Gold HMO 100 3500 BSW Plus HMO
• Gold HMO HSA 3700 BSW Plus HMO
• Gold HMO 100 3000 BSW Plus HMO
• Gold HMO 80 3000 BSW Plus HMO
• Gold HMO HSA 3200 BSW Plus HMO
• Gold HMO 100 2300 BSW Plus HMO
• Gold HMO 90 2000 BSW Plus HMO
• Gold HMO 90 1800 BSW Plus HMO
• Gold HMO 80 1500 BSW Plus HMO
• Gold HMO 80 1000 BSW Plus HMO
• Gold HMO 80 750 BSW Plus HMO
• Gold HMO copayment 0 7000 BSW Plus HMO
• Gold HMO SM 0 9200 BSW Plus HMO
• Gold PPO 90 4500 BSW Access PPO
• Gold PPO 100 4000 BSW Access PPO
• Gold PPO HSA 3700 BSW Access PPO
• Gold PPO 100 3500 BSW Access PPO
• Gold PPO HSA 3200 BSW Access PPO
• Gold PPO 100 3000 BSW Access PPO
• Gold PPO 80 3000 BSW Access PPO
• Gold PPO 100 2300 BSW Access PPO
• Gold PPO 90 2000 BSW Access PPO
• Gold PPO 90 1800 BSW Access PPO
• Gold PPO 80 1500 BSW Access PPO
• Gold PPO 80 1000 BSW Access PPO
• Gold PPO 80 750 BSW Access PPO
• Gold PPO copayment 0 7000 BSW Access PPO

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Small Group - Silver Plans (SBC)

• Silver PPO 80 8900 BSW Plus PPO
• Silver PPO 80 7500 BSW Plus PPO
• Silver PPO 100 7300 BSW Plus PPO
• Silver PPO 90 7000 BSW Plus PPO
• Silver PPO 80 6900 BSW Plus PPO
• Silver PPO 70 6700 BSW Plus PPO
• Silver PPO 90 6500 BSW Plus PPO
• Silver PPO 80 6250 BSW Plus PPO
• Silver PPO HSA 6200 BSW Plus PPO
• Silver PPO 90 5900 BSW Plus PPO
• Silver PPO 80 5000 BSW Plus PPO
• Silver PPO HSA 5100 BSW Plus PPO
• Silver PPO 70 4500 BSW Plus PPO
• Silver PPO 80 4250 BSW Plus PPO
• Silver PPO 70 3800 BSW Plus PPO
• Silver PPO 60 3250 BSW Plus PPO
• Silver PPO 90 650 BSW Plus PPO
• Silver HMO 80 8900 BSW Premier HMO
• Silver HMO 80 7500 BSW Premier HMO
• Silver HMO 100 7300 BSW Premier HMO
• Silver HMO 90 7000 BSW Premier HMO
• Silver HMO 80 6900 BSW Premier HMO
• Silver HMO 70 6700 BSW Premier HMO
• Silver HMO 90 6500 BSW Premier HMO
• Silver HMO 80 6250 BSW Premier HMO
• Silver HMO HSA 6200 BSW Premier HMO
• Silver HMO 90 5900 BSW Premier HMO
• Silver HMO 80 5000 BSW Premier HMO
• Silver HMO HSA 5100 BSW Premier HMO
• Silver HMO 70 4500 BSW Premier HMO
• Silver HMO 80 4250 BSW Premier HMO
• Silver HMO 60 4200 BSW Premier HMO
• Silver HMO 60 4200 BSW Plus HMO
• Silver HMO 70 3800 BSW Premier HMO
• Silver HMO 60 3250 BSW Premier HMO
• Silver HMO 90 650 BSW Premier HMO
• Silver HMO 80 8900 BSW Plus HMO
• Silver HMO 80 7500 BSW Plus HMO
• Silver HMO 100 7300 BSW Plus HMO
• Silver HMO 90 7000 BSW Plus HMO
• Silver HMO 80 6900 BSW Plus HMO
• Silver HMO 70 6700 BSW Plus HMO
• Silver HMO 90 6500 BSW Plus HMO
• Silver HMO 80 6250 BSW Plus HMO
• Silver HMO HSA 6200 BSW Plus HMO
• Silver HMO 90 5900 BSW Plus HMO
• Silver HMO 80 5000 BSW Plus HMO
• Silver HMO HSA 5100 BSW Plus HMO
• Silver HMO 70 4500 BSW Plus HMO
• Silver HMO 80 4250 BSW Plus HMO
• Silver HMO 70 3800 BSW Plus HMO
• Silver HMO 60 3250 BSW Plus HMO
• Silver HMO 90 650 BSW Plus HMO
• Silver PPO 80 8900 BSW Access PPO
• Silver PPO 80 7500 BSW Access PPO
• Silver PPO 100 7300 BSW Access PPO
• Silver PPO 90 7000 BSW Access PPO
• Silver PPO 80 6900 BSW Access PPO
• Silver PPO 70 6700 BSW Access PPO
• Silver PPO 90 6500 BSW Access PPO
• Silver PPO 80 6250 BSW Access PPO
• Silver PPO HSA 6200 BSW Access PPO
• Silver PPO 90 5900 BSW Access PPO
• Silver PPO 80 5000 BSW Access PPO
• Silver PPO HSA 5100 BSW Access PPO
• Silver PPO 70 4500 BSW Access PPO
• Silver PPO 80 4250 BSW Access PPO
• Silver PPO 60 4200 BSW Plus PPO
• Silver PPO 60 4200 BSW Access PPO
• Silver PPO 70 3800 BSW Access PPO
• Silver PPO 60 3250 BSW Access PPO
• Silver PPO 90 650 BSW Access PPO

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Small Group - Bronze Plans (SBC)

• Bronze PPO 100 9200 BSW Plus PPO
• Bronze PPO 90 7900 BSW Plus PPO
• Bronze PPO 80 7500 BSW Plus PPO
• Bronze PPO HSA 7300 BSW Plus PPO
• Bronze HMO 100 9200 BSW Premier HMO
• Bronze HMO 90 7900 BSW Premier HMO
• Bronze HMO 80 7500 BSW Premier HMO
• Bronze HMO HSA 7300 BSW Premier HMO
• Bronze HMO 100 9200 BSW Plus HMO
• Bronze HMO 90 7900 BSW Plus HMO
• Bronze HMO 80 7500 BSW Plus HMO
• Bronze HMO HSA 7300 BSW Plus HMO
• Bronze PPO 100 9200 BSW Access PPO
• Bronze PPO 90 7900 BSW Access PPO
• Bronze PPO 80 7500 BSW Access PPO
• Bronze PPO HSA 7300 BSW Access PPO
• Bronze HMO 100 9200 INV
• Bronze PPO 100 9200 INV

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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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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)

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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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• POS 80%/$0/$3,000/$40/$40 with RXSPS01Y
• POS 80%/$0/$3,000/$40/$40 with RXSPS03Y
• POS 80%/$0/$3,000/$40/$40 with RXSPS04Y
• POS 80%/$0/$3,000/$40/$40 with RXSPS05Y
• POS 80%/$500/$3,500/$30/$50 with RXSPS01Y
• POS 80%/$500/$3,500/$30/$50 with RXSPS02Y
• POS 80%/$500/$3,500/$30/$50 with RXSPS03Y
• POS 80%/$500/$3,500/$30/$50 with RXSPS04Y
• POS 80%/$500/$3,500/$30/$50 with RXSPS05Y
• POS 80%/$1,000/$4,000/$30/$50 with RXSPS01Y
• POS 80%/$1,000/$4,000/$30/$50 with RXSPS02Y
• POS 80%/$1,000/$4,000/$30/$50 with RXSPS03Y
• POS 80%/$1,000/$4,000/$30/$50 with RXSPS04Y
• POS 80%/$1,000/$4,000/$30/$50 with RXSPS05Y
• POS 80%/$1,500/$4,500/$30/$50 with RXSPS01Y
• POS 80%/$1,500/$4,500/$30/$50 with RXSPS03Y
• POS 80%/$1,500/$4,500/$30/$50 with RXSPS04Y
• POS 80%/$1,500/$4,500/$30/$50 with RXSPS05Y
• POS 80%/$2,000/$5,000/$30/$50 with RXSPS01Y
• POS 80%/$2,000/$5,000/$30/$50 with RXSPS03Y
• POS 80%/$2,000/$5,000/$30/$50 with RXSPS04Y
• POS 80%/$2,000/$5,000/$30/$50 with RXSPS05Y
• POS 80%/$2,500/$5,500/$30/$50 with RXSPS01Y
• POS 80%/$2,500/$5,500/$30/$50 with RXSPS03Y
• POS 80%/$2,500/$5,500/$30/$50 with RXSPS04Y
• POS 80%/$2,500/$5,500/$30/$50 with RXSPS05Y
• POS 80%/$3,000/$6,000/$30/$50 with RXSPS01Y
• POS 80%/$3,000/$6,000/$30/$50 with RXSPS02Y
• POS 80%/$3,000/$6,000/$30/$50 with RXSPS03Y
• POS 80%/$3,000/$6,000/$30/$50 with RXSPS04Y
• POS 80%/$3,000/$6,000/$30/$50 with RXSPS05Y
• POS 80%/$4,000/$8,000/$30/$50 with RXSPS02Y
• POS 80%/$4,000/$8,000/$30/$50 with RXSPS04Y
• POS 80%/$4,000/$8,000/$30/$50 with RXSPS05Y
• POS 80%/$5,000/$10,000/$30/$50 with RXSPS01Y
• POS 80%/$5,000/$10,000/$30/$50 with RXSPS02Y
• POS 80%/$5,000/$10,000/$30/$50 with RXSPS03Y
• POS 80%/$5,000/$10,000/$30/$50 with RXSPS04Y
• POS 80%/$5,000/$10,000/$30/$50 with RXSPS05Y
• POS 80%/$7,500/$15,000/$30/$50 with RXSPS03Y
• POS 80%/$7,500/$15,000/$30/$50 with RXSPS04Y
• POS 80%/$7,500/$15,000/$30/$50 with RXSPS05Y
• POS 80%/$750/$3,750/$30/$50 with RXSPS01Y
• POS 80%/$750/$3,750/$30/$50 with RXSPS02Y
• POS 80%/$750/$3,750/$30/$50 with RXSPS03Y
• POS 80%/$750/$3,750/$30/$50 with RXSPS04Y
• POS 70%/$500/$5,500/$30/$50 with RXSPS01Y
• POS 70%/$1,000/$6,000/$30/$50 with RXSPS02Y
• POS 70%/$1,000/$6,000/$30/$50 with RXSPS04Y
• POS 70%/$1,000/$6,000/$30/$50 with RXSPS05Y
• POS 70%/$1,500/$6,500/$30/$50 with RXSPS04Y
• POS 70%/$2,000/$7,000/$30/$50 with RXSPS04Y
• POS 70%/$2,500/$7,500/$30/$50 with RXSPS04Y
• POS 70%/$3,000/$8,500/$30/$50 with RXSPS01Y
• POS 70%/$3,000/$8,500/$30/$50 with RXSPS02Y
• POS 70%/$3,000/$8,500/$30/$50 with RXSPS04Y
• POS 70%/$3,000/$8,500/$30/$50 with RXSPS05Y
• POS 70%/$4,000/$11,000/$30/$50 with RXSPS01Y
• POS 70%/$4,000/$11,000/$30/$50 with RXSPS04Y
• POS 70%/$5,000/$13,500/$30/$50 with RXSPS01Y
• POS 70%/$5,000/$13,500/$30/$50 with RXSPS03Y
• POS 70%/$5,000/$13,500/$30/$50 with RXSPS04Y
• POS 70%/$5,000/$13,500/$30/$50 with RXSPS05Y
• POS 70%/$10,000/$26,000/$30/$50 with RXSPS03Y
• POS 70%/$10,000/$26,000/$30/$50 with RXSPS04Y
• POS 70%/$10,000/$26,000/$30/$50 with RXSPS05Y
• POS HSA 100%/$3,000/$5,500/0%/0% with SHDPRUY1
• POS HSA 100%/$5,000/$5,950/0%/0% with SHDPRUY1
• POS HSA 80%/$1,500/$3,000/$30/$30 with SHDPRUY2
• POS HSA 80%/$2,500/$5,000/$30/$50 with SHDPRUY2
• POS HSA 100%/$2,500/$5,500/0%/0% with SHDPRUY1
• POS HSA 80%/$3,000/$5,500/$30/$30 with SHDPRUY2
• POS HSA 80%/$5,000/$5,950/$30/$30 with SHDPRUY2
• POS 70%/$5,000/$13,500/$30/$50 with RXSPS02Y
• POS 70%/$2,000/$7,000/$30/$50 with RXSPS01Y

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