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Avera $5200 HSA Eligilble HDHP

60536SD0020011
Silver
PPO

Avera $5200 HSA Eligilble HDHP is a Silver PPO plan by Avera Health Plans.

IMPORTANT: You are viewing the 2024 version of Avera $5200 HSA Eligilble HDHP 60536SD0020011. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Avera $5200 HSA Eligilble HDHP is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Avera $5200 HSA Eligilble HDHP 60536SD0020011.
Insurer: Avera Health Plans
Network Type: PPO
Metal Type: Silver
HSA Eligible?: Yes
Plan ID: 60536SD0020011

Cost-Sharing Overview

Avera $5200 HSA Eligilble HDHP offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Avera $5200 HSA Eligilble HDHP?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Avera $5200 HSA Eligilble HDHP offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions: Abortion (except when the life of the mother is endangered), acupuncture, cosmetic surgery, dental care for adults, hearing aids, infertility treatment, long-term care, non-emergency care when traveling outside the United States, routine eye care for adults, and weight loss programs.
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Avera $5200 HSA Eligilble HDHP covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description:
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Emergency or urgent care services are covered if traveling outside of our service area. No coverage for health services if you travel outside our service area for the purpose of seeking medical treatment.
National Network: Yes

Additional Benefits and Cost-Sharing

Avera $5200 HSA Eligilble HDHP includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible
Specialist Visit
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible
Hospice Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible185.0 Days per Year
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible In-network benefit for services outside of service area. When using Out-of-Network Provider inside service area you may contact the plan to determine if your visit qualifies for in-network benefits.
Home Health Care Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible 60-visit limit per plan year for services from non-participating providers. One visit equals a maximum of 4 hours, including private duty nursing.
Emergency Room Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 0.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 0.00% Coinsurance after deductible Preauthorization for non-emergency transportation. No coverage for services without preauthorization.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible Preauthorization required. No coverage for services without preauthorization
Inpatient Physician and Surgical Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible Preauthorization required. No coverage for services without preauthorization
Bariatric Surgery
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%1.0 Procedure(s) per Lifetime Preauthorization required. No coverage for services without preauthorization
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible100.0 Days per Admission 100-day confinement limit is for services from participating providers. 60-day confinement limit for services from non-participating providers. Same confinement limit if readmitted with same diagnosis within 60 days.
Prenatal and Postnatal Care
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible Cost sharing does not apply to certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible Cost sharing does not apply to certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
Mental/Behavioral Health Outpatient Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible Coinsurance will apply for services other than therapy performed in the office or any service at a facility.
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible Preauthorization required. No coverage for services without preauthorization.
Substance Abuse Disorder Outpatient Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible Coinsurance will apply for services other than therapy performed in the office or any service at a facility.
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible
Generic Drugs
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00% Certain drugs require preauthorization. The preauthorization for the drug must be approved before the drug will be covered.
Preferred Brand Drugs
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00% Certain drugs require preauthorization. The preauthorization for the drug must be approved before the drug will be covered.
Non-Preferred Brand Drugs
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00% Certain drugs require preauthorization. The preauthorization for the drug must be approved before the drug will be covered.
Specialty Drugs
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00% Certain drugs require preauthorization. The preauthorization for the drug must be approved before the drug will be covered.
Outpatient Rehabilitation Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible Cardiac and pulmonary rehab services from participating providers are no charge after deductible and have a 36-visit maximum per plan year.
Habilitation Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible Cardiac and pulmonary rehab services from participating providers are no charge after deductible and have a 36-visit maximum per plan year.
Chiropractic Care
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Durable Medical Equipment
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00% Certain durable medical equipment require preauthorization. No coverage for services without preauthorization.
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible Some imaging requires preauthorization. Major lab and X-ray services may include PET scan, MRI, CT scan, SPECT scan, cardiovascular, nuclear medicine and MRA.
Preventive Care/Screening/Immunization
Covered
No Charge Not ApplicableNot Applicable 100.00% Age and frequency limitations may apply
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge Not ApplicableNot Applicable 100.00%1.0 Visit(s) per Year One diagnostic exam per calendar year for children under the age of 19 from a VSP provider.
Eye Glasses for Children
Covered
No Charge Not ApplicableNot Applicable 100.00%1.0 Item(s) per Year One frame from the designated pediatric eyewear collection are covered.
Dental Check-Up for Children
Covered
No Charge Not ApplicableNot Applicable 100.00%1.0 Visit(s) per 6 Months
Rehabilitative Speech Therapy
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible Cardiac and pulmonary rehab services from participating providers are no charge after deductible and have a 36-visit maximum per plan year.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible Cardiac and pulmonary rehab services from participating providers are no charge after deductible and have a 36-visit maximum per plan year.
Well Baby Visits and Care
Covered
No Charge Not ApplicableNot Applicable 100.00% Age and frequency limitations may apply
Laboratory Outpatient and Professional Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible
Basic Dental Care – Child
Covered
No Charge Not ApplicableNot Applicable 100.00%1.0 Visit(s) per 6 Months
Orthodontia – Child
Covered
Not Applicable 50.00%Not Applicable 100.00% Frequency limitations may apply
Major Dental Care – Child
Covered
Not Applicable 50.00%Not Applicable 100.00% Frequency limitations may apply
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Accidental Dental
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible
Dialysis
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible
Allergy Testing
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible
Chemotherapy
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible
Radiation
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible
Diabetes Education
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible8.0 Visit(s) per Year State law allows two education programs per lifetime and up to 8 follow-up visits per year
Prosthetic Devices
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible
Infusion Therapy
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible
Nutritional Counseling
Not Covered
Reconstructive Surgery
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible
Gender Affirming Care
Not Covered

Free Preventive Services

There is no copayment or coinsurance for any of the following Avera $5200 HSA Eligilble HDHP preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Avera $5200 HSA Eligilble HDHP including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Avera $5200 HSA Eligilble HDHP?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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