Texas Plan Benefit Materials

This booklet gives you a summary of costs and coverage in your plan. Please select the document for your plan and county:

For HMO Members:

Plan Name	CMS #	County	Summary of Benefits
Ascension Complete Seton Reward (HMO)	H6678-001	Bastrop, Burnet, Hays, Travis, Williamson	Summary of Benefits, H6678-001 - English (PDF) Summary of Benefits, H6678-001 - Spanish (PDF)
Ascension Complete Seton Secure (HMO)	H6678-002	Bastrop, Burnet, Hays, Travis, Williamson	Summary of Benefits, H6678-002 - English (PDF) Summary of Benefits, H6678-002 - Spanish (PDF)
Ascension Complete Providence Reward (HMO)	H6678-003	Bell, McLennan	Summary of Benefits, H6678-003 - English (PDF) Summary of Benefits, H6678-003 - Spanish (PDF)
Ascension Complete Providence Secure (HMO)	H6678-004	Bell, McLennan	Summary of Benefits, H6678-004 - English (PDF) Summary of Benefits, H6678-004 - Spanish (PDF)

For PPO Members:

Plan Name	CMS #	County	Summary of Benefits
Ascension Complete Seton Access Plus (PPO)	H9357- 001	Bastrop, Burnet, Hays, Travis, Williamson	Summary of Benefits, H9357-001 - English (PDF) Summary of Benefits, H9357-001 - Spanish (PDF)
Ascension Complete Seton Access (PPO)	H9357- 002	Bastrop, Burnet, Hays, Travis, Williamson	Summary of Benefits, H9357-002 - English (PDF) Summary of Benefits, H9357-002 - Spanish (PDF)
Ascension Complete Providence Access Plus (PPO)	H9357- 003	Bell, McLennan	Summary of Benefits, H9357-003 - English (PDF) Summary of Benefits, H9357-003 - Spanish (PDF)
Ascension Complete Providence Access (PPO)	H9357- 004	Bell, McLennan	Summary of Benefits, H9357-004 - English (PDF) Summary of Benefits, H9357-004 - Spanish (PDF)

This booklet gives you a complete list of services, limitations and exclusions for your plan coverage. Please select the document for your plan and county:

For HMO Members:

Plan Name	CMS #	County	Evidence of Coverage
Ascension Complete Seton Reward (HMO)	H6678-001	Bastrop, Burnet, Hays, Travis, Williamson	Evidence of Coverage, H6678-001 - English (PDF) Evidence of Coverage, H6678-001 - Spanish (PDF)
Ascension Complete Seton Secure (HMO)	H6678-002	Bastrop, Burnet, Hays, Travis, Williamson	Evidence of Coverage, H6678-002 - English (PDF) Evidence of Coverage, H6678-002 - Spanish (PDF)
Ascension Complete Providence Reward (HMO)	H6678-003	Bell, McLennan	Evidence of Coverage, H6678-003 - English (PDF) Evidence of Coverage, H6678-003 - Spanish (PDF)
Ascension Complete Providence Secure (HMO)	H6678-004	Bell, McLennan	Evidence of Coverage, H6678-004 - English (PDF) Evidence of Coverage, H6678-004 - Spanish (PDF)

For PPO Members:

Plan Name	CMS #	County	Evidence of Coverage
Ascension Complete Seton Access Plus (PPO)	H9357- 001	Bastrop, Burnet, Hays, Travis, Williamson	Evidence of Coverage, H9357- 001 – English (PDF) Evidence of Coverage, H9357- 001 – Spanish (PDF)
Ascension Complete Seton Access (PPO)	H9357- 002	Bastrop, Burnet, Hays, Travis, Williamson	Evidence of Coverage, H9357-002 - English (PDF) Evidence of Coverage, H9357-002 - Spanish (PDF)
Ascension Complete Providence Access Plus (PPO)	H9357- 003	Bell, McLennan	Evidence of Coverage, H9357-003 - English (PDF) Evidence of Coverage, H9357-003 - Spanish (PDF)
Ascension Complete Providence Access (PPO)	H9357- 004	Bell, McLennan	Evidence of Coverage, H9357-004 - English (PDF) Evidence of Coverage, H9357-004 - Spanish (PDF)

Ascension Complete Seton Reward (HMO)

Ascension Complete Providence Reward (HMO)

Plan Name	CMS #	County	Summary of Benefits
Ascension Complete Seton Reward (HMO)	H6678-001	Bastrop, Burnet, Caldwell, Hays, Lee, Llano, Travis, Williamson	Summary of Benefits, H6678-001 - English (PDF) Summary of Benefits, H6678-001 - Spanish (PDF)
Ascension Complete Seton Secure (HMO)	H6678-002	Bastrop, Burnet, Caldwell, Hays, Lee, Llano, Travis, Williamson	Summary of Benefits, H6678-002 - English (PDF) Summary of Benefits, H6678-002 - Spanish (PDF)
Ascension Complete Providence Reward (HMO)	H6678-003	Bell, Coryell, Hill, Lampasas, McLennan	Summary of Benefits, H6678-003 - English (PDF) Summary of Benefits, H6678-003 - Spanish (PDF)
Ascension Complete Providence Secure (HMO)	H6678-004	Bell, Coryell, Hill, Lampasas, McLennan	Summary of Benefits, H6678-004 - English (PDF) Summary of Benefits, H6678-004 - Spanish (PDF)

Plan Name	CMS #	County	Summary of Benefits
Ascension Complete Seton Access Plus (PPO)	H9357- 001	Bastrop, Burnet, Caldwell, Hays, Lee, Llano, Travis, Williamson	Summary of Benefits, H9357-001 - English (PDF) Summary of Benefits, H9357-001 - Spanish (PDF)
Ascension Complete Seton Access (PPO)	H9357- 002	Bastrop, Burnet, Caldwell, Hays, Lee, Llano, Travis, Williamson	Summary of Benefits, H9357-002 - English (PDF) Summary of Benefits, H9357-002 - Spanish (PDF)
Ascension Complete Providence Access Plus (PPO)	H9357- 003	Bell, Coryell, Hill, Lampasas, McLennan	Summary of Benefits, H9357-003 - English (PDF) Summary of Benefits, H9357-003 - Spanish (PDF)
Ascension Complete Providence Access (PPO)	H9357- 004	Bell, Coryell, Hill, Lampasas, McLennan	Summary of Benefits, H9357-004 - English (PDF) Summary of Benefits, H9357-004 - Spanish (PDF)

Plan Name	CMS #	County	Evidence of Coverage
Ascension Complete Seton Reward (HMO)	H6678-001	Bastrop, Burnet, Caldwell, Hays, Lee, Llano, Travis, Williamson	Evidence of Coverage, H6678-001 - English (PDF) Evidence of Coverage, H6678-001 - Spanish (PDF) Dental Benefit Details - English (PDF) Dental Benefit Details - Spanish (PDF)
Ascension Complete Seton Secure (HMO)	H6678-002	Bastrop, Burnet, Caldwell, Hays, Lee, Llano, Travis, Williamson	Evidence of Coverage, H6678-002 - English (PDF) Evidence of Coverage, H6678-002 - Spanish (PDF) Dental Benefit Details - English (PDF) Dental Benefit Details - Spanish (PDF)
Ascension Complete Providence Reward (HMO)	H6678-003	Bell, Coryell, Hill, Lampasas, McLennan	Evidence of Coverage, H6678-003 - English (PDF) Evidence of Coverage, H6678-003 - Spanish (PDF) Dental Benefit Details - English (PDF) Dental Benefit Details - Spanish (PDF)
Ascension Complete Providence Secure (HMO)	H6678-004	Bell, Coryell, Hill, Lampasas, McLennan	Evidence of Coverage, H6678-004 - English (PDF) Evidence of Coverage, H6678-004 - Spanish (PDF) Dental Benefit Details - English (PDF) Dental Benefit Details - Spanish (PDF)

Plan Name	CMS #	County	Evidence of Coverage
Ascension Complete Seton Access Plus (PPO)	H9357- 001	Bastrop, Burnet, Caldwell, Hays, Lee, Llano, Travis, Williamson	Evidence of Coverage, H9357- 001 – English (PDF) Evidence of Coverage, H9357- 001 – Spanish (PDF) Dental Benefit Details - English (PDF) Dental Benefit Details - Spanish (PDF)
Ascension Complete Seton Access (PPO)	H9357- 002	Bastrop, Burnet, Caldwell, Hays, Lee, Llano, Travis, Williamson	Evidence of Coverage, H9357-002 - English (PDF) Evidence of Coverage, H9357-002 - Spanish (PDF) Dental Benefit Details - English (PDF) Dental Benefit Details - Spanish (PDF)
Ascension Complete Providence Access Plus (PPO)	H9357- 003	Bell, Coryell, Hill, Lampasas, McLennan	Evidence of Coverage, H9357-003 - English (PDF) Evidence of Coverage, H9357-003 - Spanish (PDF) Dental Benefit Details - English (PDF) Dental Benefit Details - Spanish (PDF)
Ascension Complete Providence Access (PPO)	H9357- 004	Bell, Coryell, Hill, Lampasas, McLennan	Evidence of Coverage, H9357-004 - English (PDF) Evidence of Coverage, H9357-004 - Spanish (PDF) Dental Benefit Details - English (PDF) Dental Benefit Details - Spanish (PDF)

Plan Name	CMS #	County	Annual Notice of Changes (ANOC)
Ascension Complete Seton Reward (HMO)	H6678-001	Bastrop, Burnet, Caldwell, Hays, Lee, Llano, Travis, Williamson	Annual Notice of Changes, H6678-001 - English (PDF) Annual Notice of Changes, H6678-001 - Spanish (PDF)
Ascension Complete Seton Secure (HMO)	H6678-002	Bastrop, Burnet, Caldwell, Hays, Lee, Llano, Travis, Williamson	Annual Notice of Changes, H6678-002 - English (PDF) Annual Notice of Changes, H6678-002 - Spanish (PDF)
Ascension Complete Providence Reward (HMO)	H6678-003	Bell, Coryell, Hill, Lampasas, McLennan	Annual Notice of Changes, H6678-003 - English (PDF) Annual Notice of Changes, H6678-003 - Spanish (PDF)
Ascension Complete Providence Secure (HMO)	H6678-004	Bell, Coryell, Hill, Lampasas, McLennan	Annual Notice of Changes, H6678-004 - English (PDF) Annual Notice of Changes, H6678-004 - Spanish (PDF)

Plan Name	CMS #	County	Annual Notice of Changes (ANOC)
Ascension Complete Seton Access Plus (PPO)	H9357- 001	Bastrop, Burnet, Caldwell, Hays, Lee, Llano, Travis, Williamson	Annual Notice of Changes, H9357-001 - English (PDF) Annual Notice of Changes, H9357-001 - Spanish (PDF)
Ascension Complete Seton Access (PPO)	H9357- 002	Bastrop, Burnet, Caldwell, Hays, Lee, Llano, Travis, Williamson	Annual Notice of Changes, H9357-002 - English (PDF) Annual Notice of Changes, H9357-002 - Spanish (PDF)
Ascension Complete Providence Access Plus (PPO)	H9357- 003	Bell, Coryell, Hill, Lampasas, McLennan	Annual Notice of Changes, H9357-003 - English (PDF) Annual Notice of Changes, H9357-003 - Spanish (PDF)
Ascension Complete Providence Access (PPO)	H9357- 004	Bell, Coryell, Hill, Lampasas, McLennan	Annual Notice of Changes, H9357-004 - English (PDF) Annual Notice of Changes, H9357-004 - Spanish (PDF)

Plan Name	CMS #	County	Welcome Kit
Ascension Complete Seton Reward (HMO)	H6678-001	Bastrop, Burnet, Caldwell, Hays, Lee, Llano, Travis, Williamson	Welcome Kit, H6678-001 - English (PDF)
Ascension Complete Seton Secure (HMO)	H6678-002	Bastrop, Burnet, Caldwell, Hays, Lee, Llano, Travis, Williamson	Welcome Kit, H6678-002 - English (PDF)
Ascension Complete Providence Reward (HMO)	H6678-003	Bell, Coryell, Hill, Lampasas, McLennan	Welcome Kit, H6678-003 - English (PDF)
Ascension Complete Providence Secure (HMO)	H6678-004	Bell, Coryell, Hill, Lampasas, McLennan	Welcome Kit, H6678-004 - English (PDF)

Plan Name	CMS #	County	Welcome Kit
Ascension Complete Seton Access Plus (PPO)	H9357- 001	Bastrop, Burnet, Caldwell, Hays, Lee, Llano, Travis, Williamson	Welcome Kit, H9357- 001 – English (PDF)
Ascension Complete Seton Access (PPO)	H9357- 002	Bastrop, Burnet, Caldwell, Hays, Lee, Llano, Travis, Williamson	Welcome Kit, H9357-002 - English (PDF)
Ascension Complete Providence Access Plus (PPO)	H9357- 003	Bell, Coryell, Hill, Lampasas, McLennan	Welcome Kit, H9357-003 - English (PDF)
Ascension Complete Providence Access (PPO)	H9357- 004	Bell, Coryell, Hill, Lampasas, McLennan	Welcome Kit, H9357-004 - English (PDF)

If you have any questions please, contact Member Services.

Texas Plan Benefit Materials

Summary of Benefits

For HMO Members:

For PPO Members:

Evidence of Coverage (EOC)

For HMO Members:

For PPO Members:

Over-the-Counter Benefits

Optional Benefit Individual Enrollment Form

Optional Supplemental Benefits

Ascension Complete Seton Reward (HMO)

Ascension Complete Providence Reward (HMO)

Member Newsletter

Texas Plan Benefit Materials

Summary of Benefits

For HMO Members:

For PPO Members:

Evidence of Coverage (EOC)

For HMO Members:

For PPO Members:

Annual Notice of Changes (ANOC)

For HMO Members:

For PPO Members:

Over-the-Counter Catalog

Member Newsletter

Extra Help

Welcome Kit

For HMO Members:

For PPO Members: