BSWH Employee Plan

2027 SBCs

2026 SBCs

Resources

Member forms

• Authorization to release protected health information (PHI)
• Authorization to release protected health information (PHI)
• Medical claim form
• Transition of care form
• Transition of care form
• Other insurance form

Member handouts

Special coverage options

Out-of-area (OOA) coverage

Only available with BSWH PPO and BSWH HDHP plans

Employees and covered dependents who live 40+ miles from the nearest Tier 1 acute care hospital may qualify to receive Tier 1 benefits when using Tier 2 providers.

How to activate coverage

• Contact the BSWHP Member Service Center at 844.843.3229 before receiving care.
• If your coverage has already been activated, no further action is required.
• If you no longer live 40 or more miles from a Tier 1 acute care hospital, contact BSWHP to deactivate your Out-of-Area Coverage.

Tier 1 Exception Program

Only available with the BSWH PPO and BSWH HDHP plans

If a Tier 1 provider is not reasonably available for a covered service, eligible members may request a Tier 1 Exception. When approved, covered services received from a designated Tier 2 or Tier 3 provider will be covered at the Tier 1 benefit level.

How to request a Tier 1 exception

• Contact the BSWHP Member Service Center at 844.843.3229 before receiving care.
• Requests are reviewed based on provider availability and the following network access standards:
  • Urban areas (population greater than 500,000): Primary Care Providers (PCPs) and hospitals within 10 miles; specialists within 25 miles.
  • Rural areas (population less than 500,000): Primary Care Providers (PCPs) and hospitals within 25 miles; specialists within 45 miles.
• Approval must be obtained prior to receiving care for Tier 1 benefits to apply.

Note: Approvals do not guarantee coverage for all services. All services remain subject to plan benefits, exclusions, and medical necessity requirements.