Avera $4800 – PPO
73% cost sharing reduction [Popular Plan]
Network type: PPO
Coverage tier: Silver
Primary care visit: $15 copay
Specialist visit: $40 copay
Urgent care visit: $15 copay
Description
This plan has 73% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | PPO |
| Deductible | $4,800 per person $4,800 per person |
| Out-of-pocket max | $6,700 per person $13,400 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $15 copay |
| Specialist visit | $40 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $15 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 | $15 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 30% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | 30% coinsurance after deductible |
| Brand | 30% coinsurance after deductible |
| Non-preferred Brand | 30% coinsurance after deductible |
| Specialty | 30% coinsurance after deductible |
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 | $15 copay |
| Psychiatric hospital stay | 30% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.averahealthplans.com/app/files/public/ed43114c-d3fe-4152-a78e-097ba7e90e2a/SBC/2024/2024-SD-Avera-4800.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/ |
