Avera $6800 Medical Deductible with $50 Rx Deductible – PPO
Network type: PPO
Coverage tier: Expanded Bronze
Primary care visit: $50 copay after deductible, 40% coinsurance after deductible
Specialist visit: 40% coinsurance after deductible
Urgent care visit: $50 copay after deductible, 40% coinsurance after deductible
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 | $9,100 per person $18,200 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $50 copay after deductible, 40% coinsurance after deductible |
| Specialist visit | 40% coinsurance after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay after deductible, 40% coinsurance after deductible |
| Emergency room | 40% coinsurance after deductible |
| Ambulance | 40% coinsurance after deductible |
| Hospital stay (facility) | 40% coinsurance after deductible |
| Hospital stay (physician) | 40% coinsurance after deductible |
| Outpatient procedure (facility) | 40% coinsurance after deductible |
| Outpatient procedure (physician) | 40% coinsurance after deductible |
| Physical rehabilitation | $50 copay after deductible, 40% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 40% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $15 copay after deductible |
| Brand | $50 copay after deductible |
| Non-preferred Brand | $150 copay after deductible |
| Specialty | 30% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 40% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 40% coinsurance after deductible |
| Blood work | 40% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $50 copay after deductible, 40% coinsurance after deductible |
| Psychiatric hospital stay | 40% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.averahealthplans.com/app/files/public/32771c11-a36f-45a8-beb1-6b94ee2d758c/SBC/2024/2024-SD-Avera-6800-Medical-Deductible-50-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/ |
