Avera - Avera 5500

South Dakota, 2019

  • Plan Type

    PPO

  • Metal Tier

    Bronze

  • Out of Pocket Maximum

    $7,900

  • Deductible

    $5,500

Enroll Now
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Call (855) 866-5590 to speak with a licensed agent about a new health plan.

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Cost Sharing Benefits (In Network)

Policyholders are generally responsible for 100% of costs until the deductible amount is met. After the deductible has been met the policyholder is responsible for the coinsurance / copay until the out of pocket maximum is reached at which point the insurance company assumes 100% of all costs.

Deductible (Individual) $5,500
Deductible (Family) $11,000
Coinsurance Not applicable
Out of Pocket Maximum (Individual) $7,900
Out of Pocket Maximum (Family) $15,800

Doctor Visits

Primary Care Visit $40 Copay after deductible + 40% Coinsurance after deductible
Specialist Visit 40% Coinsurance after deductible
Inpatient Facility 40% Coinsurance after deductible
Inpatient Physician 40% Coinsurance after deductible
Emergency Room Services 40% Coinsurance after deductible

Tests and Imaging

Imaging (CT/PET Scans, MRIs) 40% Coinsurance after deductible
Laboratory Outpatient and Professional Services 40% Coinsurance after deductible
X-Ray and Diagnostic Imaging 40% Coinsurance after deductible

Health Management Programs

Asthma Available
Depression Not available
Diabetes Available
Heart Disease Available
High Blood Pressure / High Cholesterol Available
Lower Back Pain Not available
Pain Management Not available
Pregnancy Available
Weight Loss Not available

Other

Mental / Behavioral Health Inpatient 40% Coinsurance after deductible
Mental / Behavioral Health Outpatient $40 Copay after deductible + 40% Coinsurance after deductible
Rehabilitative Speech Therapy $40 Copay after deductible + 40% Coinsurance after deductible
Rehabilitative Occupational & Physical Therapy $40 Copay after deductible + 40% Coinsurance after deductible
Outpatient Facility 40% Coinsurance after deductible
Outpatient Surgery 40% Coinsurance after deductible

Prescription Drugs

Generic Rx $20 Copay after deductible
Preferred Brand Rx $75 Copay after deductible
Non Preferred Brand Rx $150 Copay after deductible
Specialty Drugs 40% Coinsurance after deductible

Other Plans in South Dakota

Plan Avera 2750 Deductible $2,750 Coinsurance Not applicable Out of Pocket $7,100
Plan Avera 4000 Deductible $4,000 Coinsurance Not applicable Out of Pocket $4,000
Plan Avera Preferred 3500 Deductible $3,500 Coinsurance Not applicable Out of Pocket $7,500
Plan Avera 3500 Deductible $3,500 Coinsurance Not applicable Out of Pocket $7,500
Plan Avera Preferred 5500 Deductible $5,500 Coinsurance Not applicable Out of Pocket $7,900
Plan Avera 6750 Deductible $6,750 Coinsurance Not applicable Out of Pocket $6,750
Plan Avera 1500 Deductible $1,500 Coinsurance Not applicable Out of Pocket $3,500
Plan Avera 7900 Deductible $7,900 Coinsurance Not applicable Out of Pocket $7,900
Plan Avera Preferred 2750 Deductible $2,750 Coinsurance Not applicable Out of Pocket $7,100
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Cost Sharing Benefits (In Network)

Policyholders are generally responsible for 100% of costs until the deductible amount is met. After the deductible has been met the policyholder is responsible for the coinsurance / copay until the out of pocket maximum is reached at which point the insurance company assumes 100% of all costs.

Deductible (Individual) $5,500
Deductible (Family) $11,000
Coinsurance Not applicable
Out of Pocket Maximum (Individual) $7,900
Out of Pocket Maximum (Family) $15,800

Doctor Visits

Primary Care Visit $40 Copay after deductible + 40% Coinsurance after deductible
Specialist Visit 40% Coinsurance after deductible
Inpatient Facility 40% Coinsurance after deductible
Inpatient Physician 40% Coinsurance after deductible
Emergency Room Services 40% Coinsurance after deductible

Tests and Imaging

Imaging (CT/PET Scans, MRIs) 40% Coinsurance after deductible
Laboratory Outpatient and Professional Services 40% Coinsurance after deductible
X-Ray and Diagnostic Imaging 40% Coinsurance after deductible

Health Management Programs

Asthma Available
Depression Not available
Diabetes Available
Heart Disease Available
High Blood Pressure / High Cholesterol Available
Lower Back Pain Not available
Pain Management Not available
Pregnancy Available
Weight Loss Not available

Other

Mental / Behavioral Health Inpatient 40% Coinsurance after deductible
Mental / Behavioral Health Outpatient $40 Copay after deductible + 40% Coinsurance after deductible
Rehabilitative Speech Therapy $40 Copay after deductible + 40% Coinsurance after deductible
Rehabilitative Occupational & Physical Therapy $40 Copay after deductible + 40% Coinsurance after deductible
Outpatient Facility 40% Coinsurance after deductible
Outpatient Surgery 40% Coinsurance after deductible

Prescription Drugs

Generic Rx $20 Copay after deductible
Preferred Brand Rx $75 Copay after deductible
Non Preferred Brand Rx $150 Copay after deductible
Specialty Drugs 40% Coinsurance after deductible

Other Plans in South Dakota

Plan Avera 2750 Deductible $2,750 Coinsurance Not applicable Out of Pocket $7,100
Plan Avera 4000 Deductible $4,000 Coinsurance Not applicable Out of Pocket $4,000
Plan Avera Preferred 3500 Deductible $3,500 Coinsurance Not applicable Out of Pocket $7,500
Plan Avera 3500 Deductible $3,500 Coinsurance Not applicable Out of Pocket $7,500
Plan Avera Preferred 5500 Deductible $5,500 Coinsurance Not applicable Out of Pocket $7,900
Plan Avera 6750 Deductible $6,750 Coinsurance Not applicable Out of Pocket $6,750
Plan Avera 1500 Deductible $1,500 Coinsurance Not applicable Out of Pocket $3,500
Plan Avera 7900 Deductible $7,900 Coinsurance Not applicable Out of Pocket $7,900
Plan Avera Preferred 2750 Deductible $2,750 Coinsurance Not applicable Out of Pocket $7,100