Avera Direct $4000 Medical Deductible with $0 Rx Deductible – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $50 copay
Specialist visit: $100 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | Success
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| 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/4204bc04-05fa-4437-8a50-b39105a56b02/SBC/2024/2024-SD-Avera-Direct-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/ |
