Avera $5800 – PPO

Network type: PPO
Coverage tier: Silver
Primary care visit: $20 copay
Specialist visit: $50 copay
Urgent care visit: $20 copay

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Description

Health Care Plan Details

Network type PPO
Deductible $5,800 per person $5,800 per person
Out-of-pocket max $8,000 per person $16,000 per family
Metal tier Silver

Visit Copay

Primary care visit $20 copay
Specialist visit $50 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $20 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 $20 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 $20 copay
Psychiatric hospital stay 30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://www.averahealthplans.com/app/files/public/87744a25-c3f0-4213-a0d7-76d7cfd4db97/SBC/2024/2024-SD-Avera-5800.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/