Avera $4000 Medical Deductible with $0 Rx Deductible – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	Success Your progress has been saved. We have sent an email to with a link to continue your application ×
Out-of-pocket max	$9,000 per person $18,000 per family
Metal tier	Silver

Visit Copay

Primary care visit	$50 copay
Specialist visit	$100 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$50 copay
Emergency room	30% coinsurance after deductible
Ambulance	30% coinsurance after deductible
Hospital stay (facility)	30% coinsurance after deductible
Hospital stay (physician)	30% coinsurance after deductible
Outpatient procedure (facility)	30% coinsurance after deductible
Outpatient procedure (physician)	30% coinsurance after deductible
Physical rehabilitation	$50 copay

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$12 copay
Brand	$40 copay
Non-preferred Brand	$125 copay
Specialty	30% coinsurance

Lab Tests and Diagnostic Procedures

X-rays	30% coinsurance after deductible
Imaging (CT/PET/MRI)	30% coinsurance after deductible
Blood work	30% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$50 copay
Psychiatric hospital stay	30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.averahealthplans.com/app/files/public/ac5cb0c8-5750-44b5-b4c0-be2680cb8cfe/SBC/2024/2024-SD-Avera-4000-Medical-Deductible-0-Rx-Deductible.pdf
Drug and medication plan formulary	https://fm.formularynavigator.com/FBO/221/Avera_Health_HYBRID_6_Tier_2024_Formulary_Output.pdf
Search doctor list	https://www.avera.org/marketplace/provider-directory/